f- 


I 


^Ul^l 


MEDICAL  EDUCATION  IN  AlEEICA: 


BEING    THE 


ANNUAL  ADDRESS 


READ   BEFORE 


THE  MASSACHUSETTS  MEDICAL  SOCIETY, 

June  7,  1871. 


HENRY  J.  BIGELOW,  M.  D., 

PROFESSOR    OF    SURGERY    IN    HARVARD    UNIVERSITY 


CAMBRIDGE: 
WELCH,   BIGELOW,   AND    COMPANY, 

]871. 


I  V 


MEDICAL  EDUCATIO^f  IN  AMERICA. 


Having  on  former  occasions  said  something  of 
Medical  Science  and  Medical  Art,  I  propose  here  to 
offer  a  few  practical  considerations  on  Medical  Edu- 
cation, with  reference  both  to  its  daily  use  and  to 
the  progress  of  medical  knowledge. 

1  am  well  aware  that  he  who  inculcates  in  general 
terms  a  high  standard  of  knowledge,  and  bids  God- 
speed to  progress,  has  a  far  more  grateful  task,  in 
the  approval  of  others,  and  possibly  of  himself,  than 
he  who  stops  to  direct  or  limit  it  by  any  considera- 
tions of  its  relative  utility.  But  in  an  age  of  science, 
like  the  present,  there  is  more  danger  that  the  aver- 
age medical  student  will  be  drawn  from  what  is  prac- 
tical, useful,  and  even  essential,  by  the  w^ell-meant 
enthusiasm  of  the  votaries  of  less  applicable  sciences, 
than  that  he  will  suffer  from  want  of  knowledcre  of 
these;  and  I  am  quite  aware  that  I  may  not  hope 
for  the  fiivorable  consideration  of  some  of  my  friends, 
when  I  say,  that,  if  there  is  any  idea  which  I  par- 
ticularly desire  to  present  distinctly  in  these  remarks, 
it  is  that  of  utility  in  medical  education. 

The  zealous  devotee  of  less  serviceable  science, 
to  whom  the   world  is  indeed   under  oblisration  for 


his  often  inadequately  requited  labors,  whether  in 
extending  or  in  merely  cultivating  the  domain  of 
human  knowledge,  may  well  be  pardoned  the  con- 
viction that  it  is  worthy  of  pursuit  for  its  own  sake ; 
but  he  should  guard  against  the  fallacious  belief  that 
it  offers  quite  as  good  an  investment  of  time  as  if  it 
had  an  immediate  and  determinate  practical  value, 
and  especially  against  a  nebulous  feeling  that  there 
is  a  savor  of  earthiness  in  the  pursuit  of  knowledge 
which  is  likely  to  be  soon  worth  something. 

The  lapse  of  centuries  has  removed  the  amulet 
from  the  physician's  sanctum,  and  the  stuffed  alliga- 
tor from  his  ceiling.  Astrology,  Astronomy,  and  even 
Natural  History,  are  known  to  have  no  immediate 
connection  with  Pathology  and  Therapeutics  ;  and 
as  the  area  of  our  science  expands,  we  shall  not  only 
continue  to  eschew  error,  but  shall  leave  to  one  side 
more  and  more  of  real  truth  pertaining  less  directly  to 
it,  still  utilizing  and  incorporating  its  valuable  results, 
and  still  finding  an  ample  field  of  study  beyond  the 
compass  of  any  one  individual.  If,  on  the  other 
hand,  it  is  fair  to  inveigh  against  a  quackery  which 
makes  plain  things  difficult,  buries  principles  be- 
neath details,  occupies  the  mind  with  mere  thera- 
peutic measures  and  routine,  and  attracts  by  per- 
sistent activity,  I  venture  also  to  question  that 
enthusiasm  which  mistakes  novelty  for  value,  and, 
overlooking  much  that  is  useful  and  practical,  ap- 
propriates with  eagerness  what  comes  authenticated 
by  recent  alleged  discovery,  or  flatters  by  a  sug- 
gestion of  exclusiveness  in  its  pursuit. 


Let  us  think  carefully,  before  exacting  from  ad- 
ult students  collateral  acquisitions  which  in  2:)ractice 
they  will  not  need,  and  actually  do  forget,  —  espe- 
cially as  much  that  is  strictly  medical  is  profitless,  or 
nearly  so,  to  the  medical  practitioner.  When,  in  Pa- 
ris, I  used  to  hear  a  lecture  upon  the  plague,  or  the 
ligature  of  the  posterior  tibial  artery,  I  thought  of 
my  fencing-master,  who  was  giving  equally  useful  in- 
struction, how,  in  case  of  attack  by  more  than  three 
men  at  once,  to  place  your  back  against  a  tree,  and, 
drawing  a  rapier,  to  dispose  successively  of  each  of 
them. 

And  yet  there  is  a  limit  to  this  line  of  argument. 
No  student  or  artisan  is  the  worse  for  an  outlook 
upon  kindred  arts  and  sciences  which  will  help  him 
to  establish  the  true  relations  of  his  own,  which  will 
supply  him  with  additional  facilities  and  light  for  its 
pursuit,  and  with  that  training  of  his  intellectual 
powers  afforded  by  a  systematic  variation  in  their 
exercise.  Let  us  concede,  then,  a  certain  latitude  to 
the  study  of  medical  science,  testing  it  rigidly  and 
constantly  by  its  applicability  to  subsequent  medical 
pursuits,  and  especially  by  a  frequent  consideration 
of  the  question,  how  far  it  occupies  the  student's  lim- 
ited time,  to  the  exclusion  of  what,  to  him,  is  more 
important. 

Two  classes  of  the  profession  at  once  claim  our 
consideration  :  those  who  are  to  do  the  daily  work  of 
medical  attendance  only,  and  those  who  may  be  ex- 
pected to  contribute  something  to  the  development 
of  medical  knowledge,  —  for  each  of  whom  a  course 


of  education  is  to  be  provided,  such  as  will  not  rise 
above  the  proper  requirements  of  the  one  nor  fall 
below  the  just  expectations  of  the  other;  or  we 
may  rather,  with  more  economy,  aim  to  devise  a 
single  system  suited  to  the  education  of  a  body 
of  students  as  routine  practitioners  and  something 
more. 

It  is  plain  that  the  mass  of  work  must  be  per- 
formed by  the  exclusive  practitioner,  who  has  been 
educated  with  the  view  of  turning  his  acquirements 
to  immediate  practical  account,  and  whose  business 
so  occupies  him  that  he  contributes  comparatively 
little  to  the  absolute  advance  of  knowledge.  Let 
us  consider  just  what  the  communit}^  should  expect 
of  this  man. 

It  has  often  occurred  to  me,  that,  if  steam  power 
should  be  substituted  on  common  roads  for  horse 
power,  collisions  would  be  of  hourly  occurrence.  It 
is  as  often  the  beast  as  the  driver  that  turns  out.  I 
hold,  that,  as  a  rule,  outside  of  surgery  and  other 
surface  work,  it  is  the  disease  that  turns  for  better 
or  for  worse,  and  not  the  physician  that  turns  it. 
Disease  often  advances  with  a  dignity  of  progress 
not  to  be  sensibly  swayed  to  one  side  or  the  other 
by  the  interference  of  the  physician.  The  balance 
of  healthy  function  is  disturbed  ;  for  a  varying  time 
the  disturbance  increases,  and  for  another  varying 
time  it  diminishes,  until  the  balance  is  restored.  A 
discourse  which  first  arrested  public  attention  here 
to  the  fact  that  it  is  useless  to  try  to  cut  short  cer- 


tain  disease,  justly  called  it  self-limited,  because,  if 
not  limited  by  its  own  inherent  tendencies,  it  as- 
suredly is  limited  by  nothing  else. 

But  let  us  not  forget,  that,  when  we  are  able  to 
limit  the  duration  of  disease,  as  we  can  that  of  fever- 
and-ague,  or,  more  completely,  syphilis,  then  it  will 
be  no  longer,  as  now,  self-limited,  but  subjugated  and 
controlled,  —  and  that  this  may  be  the  future  of  any 
disease,  not  excepting  tubercle  and  malignant  affec- 
tion, the  failure  and  the  exuberance  of  vitality,  and 
even  of  old  age  itself,  provided  only  the  chemist 
will  manufiicture,  as  he  of  late  promises  to  do,  the 
vital  spark.  So  that,  if  a  large  majority  of  fevers, 
epidemics,  the  more  serious  derangements  of  vis- 
cera, whether  of  structure  or  function,  are  as  yet 
little  controlled  by  anything  wdiich  the  physician 
prescribes,  we  are  neither  to  doubt  of  future  pro- 
gress nor  to  lose  sight  of  accomplished  results,  of 
all  that  can  now  be  done  to  arrest  disease  or  to 
alleviate  it. 

An  accurate  and  well-defined  knowledge  of  un- 
disputed therapeutic  principles  and  details  should 
be  exacted  from  every  practitioner  claiming  to  be 
properly  qualified.  He  should  know  how  to  treat, 
and  of  course  how  to  identify,  all  common  injuries 
and  diseases,  so  that  health  shall  be  reestablished  in 
the  shortest  time,  whether  by  interference  or  by  a 
resolute  refusal  to  interfere.  And  you  are  to  pro- 
vide fifty  such  plain  and  competent  men  for  one 
who  knows  more. 

Look  at  the  reverse  of  the  picture,  —  at  a  practi- 


tioner  deficient  in  respect  to  the  quantity  or  the 
quality  of  his  education,  —  accomplished  in  the 
right  direction,  it  may  be,  but  also  learned  in  the 
wrong,  —  who  tells  a  patient  he  is  bilious,  and  refers 
every  pain  in  the  side  to  the  liver,  —  who  cures 
rheumatism  with  colchicum,  and  scarlet  fever  with 
belladonna,  and,  when  a  straw  may  break  her  back, 
handicaps  Nature  with  a  six-drug  prescription, — 
who  treats  cancer  of  the  lip  with  ointment,  till  a 
gland  swells  and  the  patient  is  lost,  paints  every 
lame  knee  with  iodine,  cauterizes  every  inflamed 
throat,  and  cannot  set  a  broken  elbow :  an  industri- 
ous, driving,  and  perhaps  thriving,  but  professionally 
incompetent  man,  —  incompetent,  not  because  igno- 
rant of  the  labyrinths  of  modern  Chemistry  and 
Physiology,  but  because  he  does  not  know  the  plain 
rule  of  thumb  practice  in  modern  medicine  and 
surgery,  —  because  he  yet  lingers  in  the  paths  of 
exploded  error,  or  turns  like  a  weathercock  to  the 
last  advertisement  of  the  apothecary  or  journalist. 
Such  a  practitioner  you  do  not  want. 

Whatever  else  it  may  or  may  not  do,  a  medi- 
cal school  should  aim  first,  then,  to  give  a  plain, 
sound,  solid  education,  without  error,  if  without 
ornament. 

For,  in  the  first  place,  you  cannot  do  better  than 
this.  It  is  the  highest  average  development  of 
which  the  mass  of  the  material  you  are  dealing  with 
is  susceptible,  in  view  of  the  character  of  its  pre- 
liminary education  and  of  the  accepted  three  years' 
term  of  study. 


9 


In  the  next  place,  you  need  not  do  better.  If 
you  can  supply  the  country  at  large  with  medical 
men  thoroughly  competent  in  all  common  medical 
matters,  able  first  to  identify  and  then  to  treat 
properly  the  local  diseases  and  lesions,  thoroughly 
imbued  at  once  with  the  simple  and  broad  princi- 
ples of  necessary  therapeutic  interference  and  with 
its  detailed  routine,  and  free  especially  from  the  en- 
tangled mass  of  therapeutic  prejudice,  error,  and  de- 
ception bequeathed  by  earlier  art,  you  have  raised 
up  a  class  of  students  superior  to  those  now  grad- 
uating from  any  medical  college  in  the  land,  and 
have  sown  seed  from  which  individual  ability  and 
individual  industry  will  develop  a  growth  far  be- 
yond the  average  of  the  present  day. 

But  there  is  another  consideration.  The  excel- 
lence of  the  practitioner  depends  far  more  upon 
good  judgment  than  great  learning.  Other  things 
being  equal,  the  best  practitioner  is  the  man  of 
soundest  judgment.  With  good  judgment,  added  to 
industry  and  fair  ability,  you  can  make  an  excellent 
practitioner  out  of  moderate  medical  acquirement, 
provided  only  it  be  of  the  right  sort.  But  without 
good  judgment,  for  which  education  is  not  a  substi- 
tute, if  you  fill  the  mind  of  the  student  with  Chem- 
istry and  Physiology  and  Drugs,  as  leading  ideas, 
the  chances  are  that  he  will  apply  this  collateral, 
imperfectly  applicable  knowledge  wrongly,  and  that 
he  will  have  to  forget  and  disuse  much  of  it  before 
he  gets  it  down  to  a  medical  working  level. 

If  any  one  who  hears  me  will  consider  to  whom 


10 


among  his  acquaintance  he  would  prefer  to  intrust 
himself  in  such  common  cases  as  make  up  the  mass 
of  medical  practice,  if  assured  of  a  kindness  and 
business  fidelity  which  shall  secure  him  a  pleasant 
and  regular  attendance,  he  will,  I  think,  decide  in 
favor  of  some  one  not  originally  distinguished  for 
large  conventional  acquirements,  who  w^as  not  prom- 
inent at  graduation,  but,  beginning  quietly,  has 
grown  and  ripened  with  experience,  —  not  the  emi- 
nent and  learned  reader  of  medical  books,  acquainted 
with  every  theory  of  fever,  who  will  analyze  him  for 
urea,  register  him  with  a  sph^gmograph,  keep  a 
thermometer  in  his  armpit,  and  generate  ozone  in 
his  apartment,  —  but  a  plainer  sort  of  man,  —  one 
whose  diagnosis  is  accurate,  whose  wide  practical  ex- 
perience and  sound  judgment  have  taught  him  not 
to  harass  disease  with  uncertain  or  conventional 
remedies,  whose  active  interference  is  cautious  and 
discriminating,  whose  mummery  is  harmless  beyond 
doubt,  —  in  short,  who  never  loses  sight  of  general 
principles,  —  who  stimulates,  depletes,  derives,  or 
narcotizes,  when  he  is  sure  the  malady  requires  it, 
does  neither  when  he  is  not  sure,  and  scrutinizes 
with  great  caution  the  contradictory  results  of  the 
favorite  prescriptions  of  the  medical  host. 

AYhile  abroad  recentlv,  I  visited  in  consultation 
with  a  distinguished  foreign  practitioner  an  Amer- 
ican child  fatally  affected  with  diphtheria,  whom  he 
was  treating  with  continued  small  doses  of  copaiba, 
which  produced  an  obviously  prostrating,  though 
unintended  catharsis.     His  argument  was,  that  the 


11 


child  was  like  to  die,  that  the  friends  required  that 
something  shoidd  be  done,  and  that  somebody  had 
recently  reported  a  number  of  cases  all  terminating 
favorably  under  this  treatment.  1  said  to  myself, 
How  much  safer  would  this  child  have  been  in  the 
hands  of  an  average  Massachusetts  physician,  who 
would  have  kept  steadily  in  view  the  importance  of 
economizing  and  supporting  its  strength!  What 
this  learned  and  distinguished  medical  philosopher 
lacked  was  judgment;  in  the  practice  of  medicine, 
if  we  do  not  set  the  landmarks  of  judgment  firmly, 
learning  may  displace  them  disastrously. 

And  incidentally,  in  this  connection,  let  me  say, 
that,  in  the  medical  examination  of  a  student,  I  have 
considered  sound  judgment  some  oflset  to  imper- 
fect knowledge.  The  young  practitioner  may  be 
safely  trusted  to  consult  his  books  before  admin- 
istering the  -active  poisons  of  the  Materia  Medica. 
A  little  extemporaneous  or  "  incompatible  "  ink  or 
soda-water,  at  his  hands,  is  innocent,  when  com- 
pared with  a  persistent  and  lifelong  misinterpreta- 
tion of  symptoms,  or  their  ill-judged  medication. 

We  are  speaking  of  practitioners,  of  the  work- 
ing men  peremptorily  demanded  by  the  community 
everywhere,  and  whom  medical  schools  are  expected 
to  furnish.  In  the  education  of  these  it  should  be 
the  aim  to  develop  good  judgment  by  a  reiteration 
of  undisputed  facts  in  their  simplest  expression,  and 
by  a  constant  reference  of  these  facts  to  such  broad 
principles  as  can  be  demonstrated  beyond  reasonable 
doubt.     The  teacher  should  keep  constantly  in  mind 


12 


the  use  »arid  application  of  the  student's  knowledge. 
He  should  never  lose  sight  of  the  fact  that  every- 
thing in  medical  instruction  is  to  be  made  wholly 
subservient  to  the  prevention  and  proper  treatment 
of  disease.  Indeed,  and  more  precisely.  Therapeu- 
tics is  the  single  leading  idea,  to  which  no  inconsid- 
erable part  of  modern  medical  education  is  sec- 
ondary, and  even  tertiary,  if  I  may  say  so.  To 
know  the  remedj'.  you  must  know  disease,  and  this 
is  Pathology;  to  know  disease,  you  must  know  health, 
and  this  is  Anatomy  and  General  Physiology;  and, 
lastly,  if  you  seduce  the  ultimate  particle  away 
from  its  friends  and  its  affinities,  and  cross-examine 
it,  this  is  Chemistry  in  its  widest  range.  But  every 
step  of  this  progression  leads  farther  and  farther 
from  the  original  object  of  medical  education,  which 
is  Therapeutics.  It  is  all  more  or  less  desirable  as 
knowledore,  if  vou  can  have  it  all:  but  if  vou  cannot, 
you  must  choose  what  is  essential  to  the  practitioner, 
and  especially  you  must  consider  what  he  can  hold  : 
and  the  mass  of  medical  students  cannot,  or  do  not, 
hold  much  at  the  end  of  three  years'  study. 

I  do  not  conceal  from  myself  that  it  would  be  de- 
sirable to  raise  the  average  level  of  medical  acquire- 
ment, skill,  and  capacity,  the  world  over.  There  can 
be  no  doubt  that  a  certain  amount  of  incompetency, 
in  our  profession  as  in  others,  escapes  through  its 
graduating  machinery,  stamped  with  the  tower-mark 
of  the  colles'es.  But  we  must  not  confound  a  want 
of  opportunity  with  its  neglect.  The  question  is, 
Exactly  what  measures  will  best  promote  a  better 


13 


education  ?  You  cannot  turn  out  medical  men  with 
the  uniform  perfection  of  Ames  shovels  or  Springfield 
muskets.  The  popular  and  specious  cry  for  raising 
the  standard  of  medical  education  comes  often  from 
those  who  know  little  of  its  difficulties,  and  it  is 
notorious  that  those  who  clamor  loudest  accomplish 
least.  The  Yicar  of  Wakefield  said  he  "  was  ever  of 
opinion  that  the  man  who  married  and  brought  up  a 
large  family  did  more  service  than  he  who  continued 
single  and  only  talked  of  population."  I  am  equally 
of  opinion,  that,  in  medical  education,  he  who  con- 
scientiously seeks  to  enlighten  his  pupils,  availing 
himself  of  the  best  means  within  his  reach,  does 
more  to  advance  medical  science  than  he  who  de- 
votes his  time  to  criticism  and  declamation  upon  the 
curriculum. 

The  last  new  medical  journal,  which  calls  on  us 
to  "lay  down  all  jealousy,  modesty,  and  reserve, 
and  come  boldly  to  the  rescue,  and  by  our  united 
labors  and  best  efforts  seek  to  build  up  medical 
science  in  our  midst,  to  the  great  elevation  of  the 
professional  standard,  as  well  as  to  the  ultimate 
good  of  our  community,"  and  then,  in  a  case  of  cere- 
bro-spinal  meningitis,  proposes  to  administer,  in  the 
course  of  eighteen  hours,  "  an  ounce  and  a  half  of 
calomel,  one  ounce  and  a  quarter  of  sulphate  of 
quinine,  and  two  ounces  of  bromide  of  potassium," 
suggests  the  character  of  much  of  the  criticism  put 
forth  on  this  subject,  both  in  public  and  private,  and 
to  which  inexperienced  persons  are  disposed  to 
listen. 


14 


These  remarks  are  not  intended  as  a  plea  for  me- 
diocrity. It  should  be  remembered  that  our  present 
system  of  medical  education,  imperfect  as  it  may  be, 
produces  men  eminent  in  science,  and  furnishes  able 
teachers  as  well  as  distinguished  practitioners.  Most 
eminent  men  are  in  a  large  degree  self-made,  and 
have  pursued  their  subject  from  the  attraction  be- 
fore them,  and  not  from  a  stimulus  behind.  The 
material  out  of  which  philosophers  are  made  is  large- 
ly supplied  from  their  own  intrinsic  and  determined 
will.  Genius  is  talent  with  a  strong  driving  power, 
whether  versatile  in  all  directions,  or  more  profita- 
blv  o'uided  bv  taste  or  circumstances  in  one  direc- 
tion.  You  cannot  create  this  talent  nor  compel  this 
taste.  You  may.  indeed,  give  it  opportunity,  but 
you  cannot  force  it. 

Nor  does  scholarship,  in  its  common  acceptation, 
insure  medical  eminence.  In  the  classes  graduating 
from  our  universities,  the  more  cultivated  scholar, 
by  reason  of  his  talent  or  training  and  power  of 
application,  rather  than  his  acquisition,  is,  indeed, 
apt  to  average  well  afterwards  in  the  paths  of 
literature  and  in  the  professions,  but  he  by  no 
means  monopolizes  the  honors  or  the  active  work 
of  life,  especially  in  the  medical  profession.  On 
the  contrary,  his  brilliant  career  often  terminates 
earlv,  throutrh  no  fault  of  his  own,  but  because  it 
has  been  mainly  the  work  of  others.  He  has 
studied  Latin.  Greek,  and  Mathematics,  not  for  an 
ulterior  object,  but  because  they  were  prescribed ; 
and  when  left  to  himself,  stimulated  neither  from 


15 


within  nor  from  without,  he  may  become  as  inef- 
fectual as  a  ship  or  a  horse  turned  loose.  Your 
medical  school  should  not  be  arranged  for  his  bene- 
fit alone. 

But  it  may  be  urged :  Perhaps  the  key-note  of 
the  student's  mind  has  not  been  struck;  perhaps 
Natural  History  or  applied  Science  might  have  de- 
veloped a  capacity  and  a  power  of  unbidden  study 
to  which  Grammar  and  Geometry  have  in  vain  ap- 
pealed.—  There  is  much  truth  in  this  view,  and  much 
has  been  recently  done  in  recognition  of  it,  in  the 
undergraduate  department  of  our  own  University, 
always  active  in  the  vanguard  of  intelligence  and 
light,  —  never  more  alive  to  the  progress  and  the 
demands  of  the  age,  never  more  full  of  vitality,  effi- 
ciency, and  promise,  than  at  this  moment.  Much 
has  been  effected  by  allowing  to  the  student  a 
latitude  in  the  choice  of  his  studies. 

But  something  yet  remains  to  be  done.  Few 
young  men  are  competent  to  make  their  own  un- 
aided choice.  Few  medical  students  take  up  a  sub- 
ject—  for  example,  Physiological  or  other  Chem- 
istry, the  Microscope,  or  any  of  the  less  immediately 
applicable  or  more  attractive  branches  —  with  the 
knowledge  how  to  apportion  it  propeily  with  refer- 
ence to  a  sound  and  well-balanced  medical  educa- 
tion, or  to  what  they  will  afterwards  need  as  practi- 
tioners. It  is  here  that  supervision  is  especially 
requisite.  And  a  wise  guidance  implies  tact  and 
patient  discrimination,  and  aims  at  what  in  adult 
education,  at  any  rate,  is  more  important  than  mere 


16 


acquisition.  —  naiuely.  acquisition  for  a  definite  and 
useful  purpose.  In  encouraging  motive,  it  develops 
principles  of  action  and  character,  conduces  to  that 
enduring  and  strenuous  effort  in  one  direction,  which 
makes  the  reputed  college  dunce,  who  has  dragged 
throuo'h  his  colleo-iate  course  in  the  last  half  of  his 
class,  persistently  wasting  his  time  with  gun,  boat, 
base-ball,  novels,  poetry,  anything  but  the  prescribed 
studies,  a  useful,  hard-working  man,  and  in  the  af- 
fairs of  life  puts  the  boy  who  has  been  a  persistent 
thorn  in  the  side  of  his  tutor  far  ahead  of  one  whose 
deliberate  standard  of  excellence  has  been  the  tutor's 
approbation  instead  of  his  own.  The  horse  dif&cult 
to  break  makes  the  best  horse.  Backbone,  unbend- 
ing though  it  be,  is  better  material  to  work  upon 
than  a  compliant  '*  mush  of  concession  "  to  the  last 
man  or  the  last  thing.  In  fine,  a  determined  and 
intelligent  purpose  is  the  surest  basis  of  all  adult 
education.  Opportunity  comes  next,  and  lastly  or- 
ganized system. 

In  these  remarks  we  have  been  drifting  toward 
the  recognition  of  a  fact  always  to  be  kept  in  view, 
that  the  period  of  the  medical  student's  curriculum 
especially  attended  with  varying  and  permanent  re- 
sults begins  with  his  graduation,  when  he  is  set 
free  and  left  mainly  to  himself 

Practically  speaking,  the  medical  student  in  this 
coimtry  then  begins  a  course  of  study  varying  with 
the  characteristics  and  habit  of  his  mind,  with  his 
power  of  application,  and  with  his  opportunities.  To 
one,  a  year   or  two  of  faithful  labor  in   Vienna  or 


17 


Berlin  or  Paris  is  an  actual  extension  of  his  previous 
three  years'  term ;  to  another,  an  equally  laborious, 
though  slower  observation,  an  analysis  combined 
with  book  study  of  cases  occurring  in  his  own 
practice,  leads  in  the  main  to  the  same  result :  both 
or  either  conducing  to  an  accumulation  of  knowl- 
edge of  the  highest  order,  and  furnishing  the  more 
learned  and  able  of  our  medical  men. 

The  schools  and  colleges  graduate  every  year  a 
horde  of  young  men,  born  to  education,  who  settle 
away  into  insignificance,  while  the  whole  land  is  full 
of  heroes  who  have  fought  their  way  to  usefulness 
and  eminence,  to  high  positions  in  the  state,  in  the 
professions,  in  the  arts,  and  in  trade,  by  sheer  force 
of  will  and  determination.  To  such  you  must  give 
opportunity ;  and  you  fail  in  the  administration  of 
your  trust,  if  you  do  not  arrange  every  part  of  your 
machinery  to  facilitate  their  progress. 

Of  two  classes  educated  to  the  same  standard,  in 
the  same  community,  the  larger  will  yield  the  great- 
er product  of  wheat  as  well  as  chaff  No  medical 
school  in  this  country,  however  disinterested  its  pro- 
fessors, can  afford  on  any  ground  to  lose  sight  of 
the  size  of  its  classes,  which  are  at  once  the  seed 
and  its  fertilizer.  If  any  school  has  not  chosen  to 
improve  the  quality  of  its  teaching  in  proportion 
to  the  increase  of  students  and  pecuniary  receipts, 
its  example  affords  no  argument  against  these  re- 
marks, which  might  be  superfluous,  had  it  not  been 
speciously  maintained  to  be  absolutely  better  to  turn 
out  a  few  graduates  educated  to  a  certain  standard 


18 


than  a  larger  number  not  educated  quite  so  well. 
The  aim  of  any  reform  in  medical  education,  in  this 
country,  should  be  to  educate  at  least  an  equal 
number  of  students  to  a  higher  standard.  If,  in 
order  to  the  better  accomplishment  of  this  object, 
some  radical  change  in  the  present  plan  of  medical 
teaching  be  demanded,  great  care  is  also  required 
lest  a  new  system  should  prove  exclusive  or  im- 
practicable to  the  many. 

With  these  preliminary  remarks,  let  us  rapidly 
review  some  of  the  various  topics  of  accepted  medi- 
cal study,  in  relation  to  a  higher  standard  of  medical 
competency. 

Observation  is  a  word  in  frequent  use  in  connec- 
tion with  medical  study.  The  secret  of  profitable 
observation  is  not  only  to  observe  accurately,  but 
also  to  know  precisely  what  to  observe.  When 
Nature  is  on  the  witness-stand,  you  may  not  ask 
her  leading  questions,  yet  you  must  ask  her  some- 
thing. If  you  say  to  a  student,  "  Here  is  a  bone, 
observe  it  carefully,"  he  may  inspect  it  intently 
like  a  dog,  and  to  as  little  profit  j  and  if,  like  the 
brute,  he  is  cut  off  from  previous  and  transmitted 
learning,  he  will  be  likely  in  the  end  to  add  quite 
as  little  to  the  sum  of  knowledge.  But  if  he  con- 
siders it  in  relation  to  other  bones,  to  its  muscular 
mechanism,  to  its  joints,  or  the  manner  of  its  forma- 
tion, —  if  he  compares,  discriminates,  and  infers,  all 
this  is  profitable  observation.  Intelligent  observa- 
tion, the   work   not  only  of  the  senses,  but  of  the 


19 


mind,  and  for  a  purpose,  is  based  upon  previous 
knowledge. 

In  medicine,  it  is,  indeed,  important  to  study  facts 
in  the  authenticity  of  actual  occurrence,  and  to  keep 
the  mind  free  from  words  and  book-learning  as  sub- 
stitutes for  these.  Let  the  student  rest  upon  ex- 
periment, and  not  on  authority.  Teach  him  to 
doubt,  until  he  has  collected  his  own  evidence  and 
made  his  own  deductions, —  but  give  his  mind  some- 
thing to  do,  as  well  as  his  eyes.  Show  him  exactly 
on  what  points  you  desire  him  to  doubt,  to  experi- 
ment, and  to  infer.  All  profitable  observation  is  to 
test  theory,  or,  in  other  words,  to  settle  doubt, — 
whether  about  the  substance  of  a  child's  marble,  the 
existence,  form,  or  meaning  of  a  protuberance  on  a 
bone,  or  the  identity  of  terrestrial  forces.  It  cannot 
be  too  strongly  borne  in  mind  that  "  observation " 
should  have  a  very  definite  purpose  and  direction. 

Again,  the  geometrician,  wishing  to  make  his 
proposition  clear,  states  it  distinctly  before  proceed- 
ing to  prove  it.  The  juggler,  on  the  other  hand, 
wishing  to  keep  you  from  understanding  what  he 
does,  never  tells  you  beforehand  what  he  is  going  to 
do.  Let  the  student,  therefore,  begin  with  a  clear 
understanding  of  what  you  are  proposing  to  demon- 
strate. Show  him  the  map,  before  you  travel  over 
the  ground.  Give  him  his  concise  abstract  hypoth- 
esis, before  you  demonstrate  it  to  his  senses  or  his 
reason.  Then  let  the  demonstration  follow  quickly, 
the  dissection  upon  the  anatomy,  the  clinical  teach- 
ing upon  the  so-called  didactic  teaching. 


20 


A  perfect  system  of  instruction  would  accomplish 
this,  and  in  Anatomy  you  accomplish  it  by  modern 
illustrated  book-anatomy,  to  which  the  student  may 
devote  himself  with  far  less  reservation  than  to 
modern  book-pathology.  There  is  no  excuse  in 
these  days  for  deficiency  of  anatomical  know^ledge- 
If  a  little  of  the  enthusiasm  which  formerly  found 
expression  in  the  production  of  elaborate  prepara- 
tions of  the  arteries,  and  in  gigantic  hearts  of  many 
colors,  now  equally  expresses  itself  in  the  attractive 
fields  of  chemical  manipulation  and  the  microscope, 
the  change  is  not  objectionable ;  it  need  not  inter- 
fere with  the  acquisition  of  a  branch,  the  increased 
modern  facilities  for  whose  study  render  a  knowledge 
of  it  compulsory,  and  w^hich  underlies  all  the  rest. 

The  gross  anatomy  of  the  viscera  is  of  such  tran- 
scendent practical  value  in  relation  to  all  disease, 
that  every  student  should  be  able  to  make  with 
perfected  skill  a  common  autopsy  of  the  healthy 
subject,  attesting  familiar  knowledge  of  the  out- 
lines, the  interlocked  masses,  and  the  economical 
packing  of  these  organs. 

The  anatomy,  I  w^ill  not  say  of  the  bones,  but  of 
certain  bones,  and  of  certain  joints,  is  essential,  not 
only  to  the  welfiire  of  the  patient,  but  to  the  good 
of  the  practitioner  himself,  —  as  in  saving  him  from 
action  at  law,  often  well  grounded,  for  malpractice. 
Such  details  every  practitioner  should  have  at  his 
fingers'  ends,  to  the  sacrifice,  if  necessary,  of  the 
multifidus  spinae,  the  cutaneous  of  Wrisberg,  the 
chorda  tympani,  or  the  two  legs  of  the  diaphragm. 


21 


A  student's  Anatomy,  for  whose  details  a  practical 
surgeon,  a  pathological  anatomist,  and  I  would  even 
add  a  physiologist,  should  vouch  by  concurrent  cer- 
tificate, would  stand  at  least  upon  a  basis  of  utility. 

The  dissecting-room,  a  school  for  manual  dexteri- 
ty as  real  to  the  surgeon  as  to  the  carpenter,  is  not 
propitious  to  intellectual  effort.  It  would  be  no  in- 
justice to  the  student  rigorously  to  require  from  him 
an  exact  knowledge  of  the  bones,  and  of  the  prin- 
cipal muscles,  arteries,  and  veins,  before  dissection, 
if  only  as  a  preliminary  exercise  in  accurate  study 
and  investigation.  There  is  no  danger  that  he  will 
here  lose  sight  of  facts  in  words.  Anatomy  thus 
acquired,  and  in  half  the  usual  time,  is  retained  im- 
measurabl}^  longer ;  and  with  a  previous  knowledge 
only  waiting  verification,  frequently  recurring  op- 
portunity invites  local,  practical  study.  On  the 
other  hand,  the  student  who  waits  to  be  inspired 
by  the  impartial  allotment  of  the  demonstrator's  hat 
will  be  very  apt  to  abandon  his  negligently  divided 
fifth,  when  he  discovers  for  himself  that  Anatomy 
enters  at  the  head  with  effort,  and  not  at  the  hand 
without  it.  A  solid  groundwork  of  Anatom}^,  never 
acquired,  if  not  acquired  at  the  outset,  is  the  most 
satisfactory  investment  of  the  beginner's  time. 

I  once  heard  a  member  of  this  Society  express 
a  plausible  satisfaction  that  his  business  lay  in  cur- 
ing disease  rather  than  in  studying  its  anatomical 
changes.  But  where  palpable  change  exists,  one 
might  as  well  ignore  the   mechanism  of  a  damaged 


99 


watch  as  undervalue  its  importance ;  and  the  more 
accurate  the  knowledge,  the  better  the  diagnosis. 
At  some  time  in  the  distant  future,  observing  the 
bronzed  patch,  or  the  hj^aline  cast,  like  a  compass, 
we  ma}'  invoke  a  specific  remedy  for  the  renal  or 
renal-caps ular  lesion  which  they  indicate,  as  we  turn 
the  ship's  wheel.  But  until  that  remote  day  when 
all  diseases  can  be  so  identified  and  arrested,  any 
appreciable  change  of  material  tissue  must  lie  in 
the  direct  road  to  Therapeutics. 

No  single  branch  of  education  is  more  essential 
to  the  medical  student  than  Pathological  Anatomy, 
the  corner-stone  of  medicine.  And  yet  it  will  hardly 
be  credited,  that,  while  its  study  is  a  matter  of  only 
secondary  importance  in  some  of  our  colleges,  chiefly 
perhaps  for  want  of  opportunity,  a  distinct  profes- 
sorship of  that  branch  existed  for  many  years  in 
Harvard  University  alone.  We  here  early  saw  the 
value  of  knowledge  resting  on  a  surer  basis  than 
pulse  and  pain  and  deranged  digestion.  Indeed,  it 
is  not  too  much  to  say  that  the  comparatively  exact 
standard  of  medical  knowledge  in  this  immediate 
community  for  the  last  thirt}'  years  has  been  largely 
due  to  the  accurate  and  disinterested  observer  who 
has  occupied  the  college  chair  of  Pathological  Anat- 
omy for  nearly  a  quarter  of  a  century. 

It  is  important  to  the  practitioner,  and  especially 
to  the  surgeon,  because  it  is  so  often  practicable,  to 
identify  a  morbid  growth  by  its  gross  appearance, 
rather  than  by  its  aspect  under  the  microscope. 


23 


1  remember  the  heresy,  years  ago,  of  a  laborious, 
sensible,  and  unostentatious  country  observer,  who 
said  that  he  had  been  able  to  find  very  little  in 
morbid  cell  growth  which  he  did  not  also  find  in 
healthy  tissue.  If  any  change  has  marked  the 
character  of  investigation  in  this  direction  during 
the  last  ten  years,  it  is  a  recognition  of  this  fact, 
in  the  study  of  the  arrangement  of  the  particles 
rather  than  the  particles  themselves,  of  the  section 
rather  than  the  cell. 

Let  me,  to  illustrate  my  own  convictions,  tran- 
scend for  a  moment  the  limits  of  strict  induction.  I 
recognize  two  underlying  formative  forces  in  the 
machinery  of  the  human  fabric,  —  one  which  trans- 
forms the  cell  and  raw  material  into  the  perfected 
tissue,  and  another  which  distributes  and  moulds 
that  tissue  to  the  outline  and  proportions  of  the 
human  body.  Without  the  latter  force  we  have 
the  amorphous  fat,  bone,  or  cartilage,  glandular  or 
uterine  tissue,  which  are  examples  of  the  so  called 
homologous  and  comparatively  innocent  growth 
or  tumor ;  while  without  the  former  we  have  the 
un transformed  cellular  and  other  raw  material  of 
heteroloo:ous  g-rowth,  whether  maliii^nant  or  benio-n. 
The  innocence  of  a  benign  growth,  connected  with 
the  fact  that  its  peripheral  cells  do  not  interfere 
with  their  neighbors,  points  to  their  dependence 
upon  some  governing  force  inherent  in  the  whole 
mass,  and  to  which  each  cell  is  subordinated ; 
while  the  principle  of  "  malignity,"  by  which  a 
neighboring    tissue    or    distant    gland    is    pervaded 


24 


and  supplanted  by  the  new  cell,  equally  points  to 
an  independent  existence  in  these  last.  In  my 
own  mind  tlie  growth  of  an  innocent  tumor  is 
associated  with  a  centralized  or  monarchical  gov- 
ernment, and  the  independent  tendencies  of  the 
cells  of  the  cancer  and  its  congeners  with  the  self- 
ruHng  elements  of  a  modern  commune,  by  an  anal- 
ogy too  close  to  be  purely  fanciful. 

All  this  points  to  a  distinction  between  similar 
growths,  based  upon  lesion  rather  of  their  inappre- 
ciable forces  than  of  any  structure  appreciable  to  the 
eye.  And  the  same  train  of  remark  may  be  applied 
to  the  isolated  cell,  of  which  two,  apparently  similar, 
like  seeds  or  eggs,  may  develop  a  widely  different 
maturity :  one  cell  benign,  of  a  reproduction  slow, 
though  progressive,  tolerant  of  its  neighbors,  and  al- 
together unobjectionable  as  a  citizen  ;  the  other  fo- 
menting evil,  insidiously  supplanting  its  neighbor,  a 
fungus  in  the  rapidity  of  its  increase,  deteriorating 
directly  or  indirectly  the  whole  system,  which  it  in- 
volves at  last  in  a  common  ruin.  And  yet  these  cells 
may  be  positively  undistinguishable.  If  Chemistry 
finds  identity  in  its  allotropism.  Pathology  equally 
finds  diversity  in  its  isomorphism. 

Modern  Science,  after  laborious  examination  of 
the  wide  range  of  growths  which  occupy  the  fields 
intermediate  between  innocence  and  malignity,  has 
in  general  terms  advanced  the  incredible  statement, 
that  "  epithelial "  cells  aggregated  in  little  chambers 
of  interlacing  meshes  may  be  classed  as  cancer,  with 
a  tendency  to  recur  widely,  while  growths  composed 


25 


of  cells  juxtaposed  without  this  chambered  tissue 
have  a  tendency  only  to  local  reproduction  ;  but  as 
this  rule  is  flir  from  having  a  practical  infallibility, 
modern  Science  hedges,  in  avowing  that  a  compe- 
tent observer  may  devote  tw^o  or  three  days  to  the 
examination  of  a  small  growth,  and  yet  fail  to  dis- 
cover some  minute  portion  of  exceptional  tissue, 
which  at  a  subsequent  time  may  dominate  the  mass 
and  overrule  its  previous  tendencies. 

To  the  practical  surgeon,  to  whom  rules  with  such 
exceptions  have  little  value,  the  great  question  with 
regard  to  these  morbid  growths  is  the  possibility  or 
probability  of  their  recurrence.  The  philosopher's- 
stone  of  the  histologist  is  a  distinction  between 
innocence  and  malignity,  divested  of  w^hich  ignis- 
fatuus.  Science  may  seem  to  the  explorer  to  have 
lost  a  part  of  its  charm.  But  this  question  the 
experienced  surgeon  or  pathologist  will  settle  with 
great  certainty,  with  a  little  occasional  assistance 
from  the  microscope,  far  short  of  the  refinements 
of  modern  Science.  Such  is  the  lesson  to  be  kept 
before  the  mind  of  the  student, —  the  clinical  utility 
of  pathological  histology. 

No  subsequent  experience  or  observation  can,  in- 
deed, ever  call  in  doubt  a  microscopic  appearance 
once  correctly  observed  and  recorded.  But  its  classi- 
fication according  to  presumed  affinities  is  as  change- 
able and  uncertain  as  groups  in  clouds  or  the  kalei- 
doscope. The  large  labor  absolutely  necessary  to 
keep  pace  with  modern,  and  especially  German  Sci- 
ence, in  this  direction,  has  a  value  to  the  student,  in 

4 


26 


directing  his  close  attention  to  the  material  of  dis- 
ease ;  but  he  may  readily  devote  to  these  attrac- 
tive studies  a  disproportionate  amount  of  time,  and, 
above  all,  lose  sight  of  the  relation  of  his  labor  to 
its  result.  Although  the  observation  of  diseased  tis- 
sue conventionally  involves  the  philosopher  in  theo- 
ries of  its  relations  and  significance  ^vhich  the  lapse 
of  every  ten  years  seems  to  subvert  and  replace 
with  a  new  crop,  it  is  difficult  to  persuade  the  stu- 
dent of  morbid  growths  under  the  microscope  that 
the  present  year  does  not  represent  the  culmination 
of  a  perfect  science,  and  that  the  last  new  doctrine 
does  not  embody  the  final  and  enduring  truth. 

Another  consideration,  in  reference  to  this  subject, 
is  the  fallacious  connection  between  names  and  things. 
A  growth,  for  example,  whose  clinical  history,  whose 
tendency,  and  whose  microscopic  structure  were 
thorouo'hlv  understood  ten  or  fifteen  vears  aero,  under 
the  arbitrary  name  of  *•  hbro-plastic,"  and  then  of 
'^  recurrent  fibroid,"  now  appears  in  the  new  role 
of  "  fasciculated  sarcoma,"  with  little  added  to  our 
practical  knowledge  of  it ;  and  the  same  is  true  of 
'^necrosis"  and  "  osteo-myelitis "  :  yet  the  student 
who  is  laboriously  admitted  to  the  new  name  be- 
lieves he  has  discovered  a  new  thing,  and  that  his 
previous  knowledge  is  allied  to  a  conservatism  past 
which  the  current  of  Science  is  rapidly  sweeping. 

In  Pathology  the  student  has  reached  the  kernel 
of  his  subject.  He  may  well  gaze  with  admiration 
at   the    magnificent    arrav    of  valuable    facts,    both 


27 


medical  and  surgical,  old  and  new,  here  spread  be- 
fore him  as  the  basis  and  solid  foundation  of  his 
future  practice  and  his  future  progress, —  striking, 
when  compared  with  those  of  former  years,  for  the 
absence  of  any  induction  which  does  not  follow  close 
upon  the  record.  Here  lies  the  gist  and  body  of  the 
student's  three  years'  work.  With  the  invaluable 
material  thus  now  collected  for  strictly  medical 
study,  in  such  works  as  those  of  Niemeyer,  Aitken, 
Holmes,  or  Billroth,  there  is  no  danger  that  he 
will  devote  a  disproportionate  period  to  that  accu- 
rate investigation  which  alone  makes  it  possible  to 
treat  disease  intelligently,  and  which  implies  a  succes- 
sive study  of  one  disease  or  small  group  of  diseases 
at  a  time.  Specialty  in  practice  unfortunately  tends 
to  encourage  hyper-practice  and  ignorant  practice, 
—  prolonged,  useless,  damaging,  —  in  which  the  prac- 
titioner may  deceive  himself,  perhaps  his  patient. 
It  narrows  therapeutic  view,  substitutes  local  for 
general  measures,  and  dwindles  to  ever-changing  in- 
struments and  methods.  Not  so  with  special  study 
in  Pathology,  which,  if  of  facts,  and  not  of  theory, 
and  proportioned  to  the  student's  time,  is  better  ac- 
cording as  it  is  more  accurate  and  elaborate. 

The  medical  Preraphaelites  of  the  old  so-called  nu- 
merical system,  whose  proselytes  did  not  hesitate  to 
pay  a  large  price  in  time  and  labor  for  its  angular 
results,  were  in  error  only  so  far  as  they  prized  this 
dry  and  exact  method  as  an  end  of  medical  study, 
rather  than  a  stao;e  of  accurate  investioration.  In 
reality,  Preraphaelite  efforts  are  valuable  chiefly  as 


28 


marking  progress,  leading  to  equally  accurate,  but 
far  more  comprehensive  generalization.  Such  labo- 
rious study  and  mathematical  exactness  were  essen- 
tial to  the  subsequent  excellence  of  the  highest  art. 
Without  it  you  may  have  the  tolerable  drawing,  the 
harmony  of  color,  and  the  occasional  good  composi- 
tion of  modern  pictures,  but  nowhere  the  combined 
perfection  of  all  these  qualities  which  distinguished 
the  great  masters  of  a  former  age,  in  whatever  school. 
You  cannot  have  the  great  generalizations  of  paint- 
ing, history,  or  natural  history,  of  science  ethical  or 
material,  of  medical  science,  whether  in  theory  or  in 
practice,  without  a  previous  accurate  knowledge  of 
detail.  And  this  is  to  be  acquired  while  the  student 
is  a  student.  Laborious  and  careful  study  must  pre- 
cede what  looks  like  careless  handling,  but  which  is 
really  a  masterly  and  free  perfection. 

With  a  generalization  of  detail,  with  a  selection  in 
each  particular  case  of  what  is  essential  and  a  simul- 
taneous rejection  of  what  is  not  so,  with  sweeping 
and  comprehensive  rapidity,  a  master  of  his  art  will 
give  you  a  mere  silhouette  of  diagnosis  and  treat- 
ment, with  a  single  broad  light  and  shadow,  every 
part  proportioned  to  the  rest,  which  may  be  far  more 
accurate  and  more  to  the  purpose  than  the  labored, 
conscientious  work  of  a  less  skilled  man.  But,  in 
the  seeming  inspiration  of  a  moment,  the  master  has 
given  you  the  concentrated  and  digested  skill  of  a 
life  of  careful  study  and  practice. 

And,  to  pursue  the  simile,  if  the  advanced  practi- 
tioner, who  has  arrived  at   his   second  and   broader 


29 


therapeutic  manner,  should  come  gradually  to  be- 
lieve that  the  treatment  of  an  old  doctor  is  better 
for  the  patient  than  the  diagnosis  of  Young  Philos- 
ophy, he  may  be  pardoned  for  forgetting  that  he 
would  stand  on  a  yet  broader  basis,  if  he  were 
master  of  every  modern  truth  of  Pathological  Anat- 
omy and  Pathology. 

The  student's  work  is  mainly  with  facts  of  empiri- 
cal association.  Proximate  cause  in  medicine  leads 
to  treacherous  ground,  which,  unless  mechanics  or 
pure  chemistry,  it  behooves  both  student  and  teach- 
er to  scrutinize  with  doubt  and  hesitation. 

The  proximate  relation  of  symptoms  and  disease 
to  contagion,  infection,  and  miasm  ;  what  smells  and 
dirt  are  unhealth}-,  —  considerations  upon  which  de- 
pend important  sanitary  measures ;  whether  albu- 
minuria is  due  to  an  oriorinal  chancre  in  the  blood; 
the  relation  of  urea  to  convulsions  ;  the  proximate 
cause  of  pyaemic  symptoms  :  such  are  questions  con- 
cerning which  no  certain  proof  has  been  adduced, 
which  are  as  likely  to  be  settled  ten  years  hence 
in  one  way  as  another,  and  are  therefore  to  be  held 
before  the  student  with  reservation. 

But  remoter  and  empirical  cause  may  be  profitable 
study.  The  assemblage  of  human  beings  as  a  cause 
of  disease,  the  probable  correlative  equivalence  or 
significance  of  the  wide  range  of  dissimilar  symptoms 
differently  affecting  the  sexes,  and  which  patholo- 
gists have  at  times  grouped  as  hysteric  or  mimotic, 
are  examples  in  point,  leading  to  broad  therapeutic 
views  and  away  from  harmful  local  interference. 


;o 


Some  jaundiced  person  might  aver,  that,  when  an 
affection  is  curable,  it  is  taken  from  the  physician 
and  handed  over  to  the  surgeon,  the  ophthahnologist, 
the  dermatologist,  or  other  speciahst,  and  that  the 
former,  bewildered  by  the  intractable  assemblage  of 
signs,  symptoms,  and  overgrown  viscera  remaining 
to  him,  and  driven  to  desperate  expedients,  is  com- 
pelled to  drug  the  patient  and  his  friends  m  self- 
defence.  But  we  cannot  set  too  high  a  value  on 
modern  Therapeutics  in  its  best  form,  —  that  science 
of  the  alleviation,  and  occasionally  of  the  arrest  of 
disease,  w^hich  is  the  ultimate  aim  of  our  art. 

A  materialism  here  productive  of  error  is  that 
which  leads  to  the  belief  that  we  can  so  far  under- 
stand the  physiological  action  of  a  drug,  that  we  can 
rely,  for  example,  upon  three  grains  of  hydriodate 
of  potash  to  produce  a  certain  three  grains'  Avorth  of 
effect,  not  upon  the  ultimate  condition  of  the  patient, 
which  it  is  well  know^n  we  can  sometimes  do,  but 
upon  his  intermediate  machinery.  Phosphorus,  it 
is  said,  supplies  brain  substance ;  but  literature  is 
probabl}^  better  fertilized  with  roast  beef  and  Sherry 
wine  than  with  fish.  We  can  better  judge  of  the 
effect  of  aloes,  juniper,  or  tea  on  the  intestines,  kid- 
ney, or  brain  of  the  next  man  by  knowing  how  it 
affected  the  last  man  than  by  any  reasoning  upon 
the  metamorphosis  of  vital  chemistry.  The  student 
who  expects  to  influence  disease  because  he  under- 
stands how  a  drug  passes  through  the  visceral  cells 
will  get  into  a  habit  of  therapeutic  reasoning  and 
action   very  likely  to   damage  the  man  or  woman 


31 


who  owns  the  viscus.  For  him,  the  established  rules 
of  art  are  safer  teaching  than  the  speculations  of 
science. 

On  the  other  hand,  we  are  not  on  this  account 
to  lose  sight  of  general  therapeutic  principles,  when 
they  can  be  clearly  established.  Students  incline  to 
lean  upon  prescriptions.  But,  except  upon  the  con- 
quered ground  of  syphilis  and  intermittent,  of  pain 
and  similar  instances  of  well-recognized  effect,  I  be- 
lieve that  a  practitioner  would  do  better  with  broad 
therapeutic  views  than  with  all  the  prescriptions 
of  the  best  medical  writers. 

The  skilful  surgeon,  who  startled  his  pupils  by 
daubing  an  ulcer  with  ink  from  his  pen,  treated  his 
patient  not  slightingly,  nor  with  indignity,  but  with 
a  simple  application  of  sulphate  of  iron,  of  tannin, 
and  of  a  principle. 

New  drugs  find  their  greatest  consumption  in 
small  communities,  where  the  standard  of  Thera- 
peutics, disturbed  by  medical  journals,  is  not  at  once 
righted  by  the  inertia  of  medical  opinion,  and  where 
the  practitioner  is  therefore  more  liable  than  else- 
where to  lose  sight  of  general  laws  in  the  routine 
of  practice. 

In  no  pursuit  of  life  is  the  judgment  more  distinct- 
ly called  upon  than  here ;  and  we  should  learn  this 
to  our  cost,  did  not  the  power  of  Nature  stand  up 
against  the  lesser  expedients  of  so-called  medication. 
The  action  of  the  medical  attendant  is  so  constantly 
based  upon  imperfect  indications, — he  so  often  finds 
it  difficult  to  decide   between  a  general   and   local 


32 


treatment,  —  the  question  is  so  often,  "  How  much 
and  how  long  ?  " —  so  often  whether  to  treat  the  body 
or  the  mind  of  the  patient,  or  the  convictions  of  his 
friends,  —  whether  to  do  something  or  to  do  nothing, 
and,  if  nothing,  how  to  do  it  with  harmless  form  and 
circumstance.  —  he  so  frequently  invokes  his  sci- 
ence hopelessly, — his  science  is  so  overcast  by  error 
inculcated  with  the  authority  of  learning  and  the 
experience  of  former  time,  —  indeed,  his  best  mod- 
ern authorities  are  so  often  fallacious,  that  it  is  no 
wonder  the  best  judgment  should  frequently  be  at 
fault. 

To  what  conclusion,  then,  may  fallacious  judgment 
lead  ?  Would  that  it  were  possible,  after  providing 
ample  teaching  in  the  magnificent  array  of  undis- 
puted facts  of  modern  Pathology,  to  add  to  it  sound 
instruction  in  the  comparatively  limited  field  of  the 
best  modern  Therapeutics,  and  then  to  endow,  as 
more  important  than  any  other  ofiice  of  tuition  in 
the  healing  art,  a  professorship  of  Common  Sense,  — 
of  which,  indeed,  all  science  has  been  said  to  be  only 
the  hio-hlv  organized  result. 

What  shall  we  saj'  of  the  Materia  Medica,  that 
wonderful  armory  of  therapeutic  warfare,  catalogued 
in  the  dispensary,  emblazoned  for  exhibition  by  the 
apothecary :  the  obsolete  weapons  of  the  savage, 
harmless  or  envenomed  ;  the  clumsy  artifices  of  the 
Middle  Ages ;  tlie  Chinese  armor,  specious  to  the 
eye  ;  the  stink-pot,  potent  to  the  sense,  side  by  side, 
without  invidious  preference,  with  the  improved  ex- 


33 


pedients  of  later  art ;  for  the  modern  expectant,  the 
wooden  guns  to  fortify  delay,  while  the  more  active 
practitioner  reflects  with  satisfaction  upon  his  trusty 
breech-loader  ? 

"  Favorite  Medical  Prescriptions,"  blowing  hot  and 
cold  at  the  same  time,  at  the  same  disease,  —  shoot- 
ing promiscuously  at  friends  and  enemies,  with  gen- 
eral good  intentions,  like  friendly  regiments  meeting 
in  the  dark, —  what  is  such  a  book,  but  the  panacea, 
on  a  large  scale,  of  that  good  physician  who  accumu- 
lated the  residuum  of  his  bottles  in  a  common  recep- 
tacle for  use  in  difficult  cases  ? 

What  precocious  wisdom  in  the  letter  written  (the 
lines  ruled  above  and  below  in  pencil)  by  the  young 
Prince  to  the  Duke,  his  tutor !  "  My  Lord,"  says  he, 
"  I  would  not  have  you  take  too  much  physic,  for 
it  doth  always  make  me  worse,  and  I  think  will  do 
the  like  with  you.  I  ride  every  day.  I  am  ready 
to  follow  any  other  directions  from  you.  Make 
haste  to  return  to  him  that  loves  you." 

The  judicious  Sir  Henry  Holland  somewhere  ven- 
tures to  doubt  whether  a  single  prescription,  contain- 
ing an  ingredient  for  each  symptom  of  a  complicated 
disease,  against  which  it  is  especially  levelled,  may 
not  perhaps  sometimes  fail  of  producing  its  whole 
intended  effect.     I  should  boldly  aver  that  it  may. 

And  yet  there  is  a  clinging  reverence  and  love 
for  the  memories,  the  associations,  the  superstitions 
connected  with  these  mysterious  agencies,  so  largely 
identified  with  the  health  of  the  human  family,  and 
the  pockets  of  the  medical  profession. 


34 


In  an  address  before  a  learned  medical  society,  to 
which  I  have  the  honor  to  belong,  a  distinguished 
friend  of  mine  once  stated,  that,  if  all  the  medicines 
in  the  world  were  thrown  into  the  sea,  it  would  be 
better  for  the  world  and  worse  for  the  fishes.  Un- 
fortunately, we  all  thought  he  said  physicians,  and 
very  properly  rose  in  a  body  to  hurl  back  the  start- 
hng  insinuation.  He  was  happily  saved  from  uni- 
versal execration  by  remembrance  of  his  stanch  and 
lifelong  devotion  to  all  that  is  honorable  and  true 
in  our  profession  and  in  the  world. 

The  matter  of  prescribing,  in  every-day  practice, 
stands  thus :  First,  does  the  disease,  on  any  ground, 
require  a  prescription?  Second,  does  the  patient? 
If  the  former,  let  the  prescription  convey  with  the 
word  the  blow ;  but  if  you  prescribe  for  the  pa- 
tient, and  not  for  the  disease,  the  prescription,  then 
an  empty  word,  a  vox,  if  need  be,  should  convey 
also  a  ^;r^^e?'ea  nihil  of  undoubted  innocence.  Ma- 
terially embodied  in  a  bottle  or  a  bath-tub,  as  an 
epithem,  a  measure,  a  restriction,  the  prceterea  nihil 
is  not  unfrequently  the  Aveights-and-scales  of  conva- 
lescence. Whole  theories  have  been  built  upon  its 
supposed  action.  The  essence  of  some  of  the  most 
successful  species  of  charlatanism,  the  emergency  for 
its  employment  in  a  visible  form  occurs  at  every 
turn ;  and  the  teacher  should  see  to  it  that  it  does 
no  mischief,  either  to  the  patient,  or  to  the  science 
of  the  practitioner. 

Opium,  narcotism,  anaesthesia,  consciousness  be- 
numbed, the   nerves   quieted,  —  what  can  the   phy- 


35 


sician  do  without  a  therapeutic  principle  to  which 
half  his  long  prescriptions  owe  their  chief,  if  not  their 
only  efficacy  ?  And  yet  it  seems  but  yesterday  that 
I  was  called  upon  to  justify  the  newly  discovered 
anaesthesia  in  a  common  defence  with  the  lightning- 
rod  and  the  umbrella.  In  a  surgical  practice  of 
twenty-five  years,  I  have  never  intentionally  given 
a  patient,  unless  by  his  own  choice,  any  unnarcotized 
pain,  nor  have  I  allowed  a  patient  to  die  a  death 
of  pain,  when  opium  would  lull  him  into  his  long 
sleep.  I  share  the  responsibility  of  this  with  the 
surgeon  who  walked  about  the  battle-field  distrib- 
uting morphine  to  those  who  were  hopelessly 
wounded,  and  with  the  soldier  of  Ambroise  Pare, 
who  did  more.  It  has  been  said,  that  to  cut  the 
nerve  of  a  lame  horse's  leg  is  like  cutting  telegraph- 
wires  to  stop  a  war ;  but  it  does  more,  in  preventing 
the  wear-and-tear  of  pain  upon  vitality.  It  has  been 
my  lot  to  see  a  friend,  at  the  end  of  a  painful  and 
hopeless  malady,  to  whom,  when  the  hour  of  death 
seemed  to  be  near  at  hand,  I  had  given  morphine 
largely,  twice  awaken  with  a  week's  new  life,  due  to 
eighteen  or  twenty-four  hours'  deep  sleep  and  con- 
tinued exemption  from  pain.  Short  of  engendering 
a  habit,  it  is  better  for  the  patient's  strength  and 
life  to  sleep  with  opium  than  to  lie  awake  with 
pain  for  the  want  of  it;  and  I  do  not  apologize  for 
remarks,  trite  though  they  be,  which  are  no  digres- 
sion from  the  subject  of  the  education  of  one  the 
great  business  of  whose  life  is  to  relieve  pain  and 
suffering,  whose  sheet-anchor,  whether  in  life  or  at 


36 


the  hour  of  death,  is  narcotism  in  some  degree  or 
form,  and  Avithout  which  his  profession,  if  not  his 
prescriptions,  would  be  comparatively  a  farce. 

A  full-blooded  Latin  prescription,  the  unabridged 
edition,  such  as  we  find  in  English  books,  is  perhaps 
the  curious  single  relic,  clinging  to  our  art,  of  its  early 
history.  And  yet  it  is  important  that  the  student 
should  acquire  so  much  of  Latin,  or,  at  any  rate,  of 
the  principles  of  that  language,  as  shall  enable  him 
readily  to  understand  the  general  character  and  con- 
struction of  the  Latin  names  of  his  therapeutic  ma- 
terials. 

Latin  is  the  accepted  language,  the  world  over,  of 
much  of  the  nomenclature  of  medical  science.  Ma- 
ranta  in  Boston  is  Maranta  in  Paris  and  in  Calcutta ; 
and  so  with  the  products  of  Chemistry.  Years  ago 
I  read  a  learned  and  protracted  controversy  upon 
the  therapeutic  properties  of  the  cow-parsnip,  ter- 
minating in  the  important  avowal  that  the  contro- 
versialists praised  each  a  different  cow-parsnip, 
whose  rival  claims  to  commendation  added  fuel  to 
the  dispute,  but  presented  insurmountable  obstacles 
to  its  conclusion.  If  the  world  are  agreed  upon  a 
single  name  for  a  drug  of  any  sort,  let  us  adopt 
it ;  and  the  world  seem  to  be  agreed  upon  the  Latin 
name.  But  it  is  a  separate  question,  whether  a 
teaspoonful  should,  of  necessity,  be  a  cochleare,  or 
even  whether  a  name  once  indicated  should  be  sus- 
ceptible of  the  terminations  of  declension.  Business 
is  but  business.     The  merchant's  price-current  does 


37 


not  say  "  of  Cochineal,"  "  of  Jute."  However  incon- 
gruous to  the  classic  sense,  and  although  the  innova- 
tion might  for  a  time  console  and  encourage  conven- 
tional ignorance,  I  would  agree  that  the  mystic  1^ 
be  accepted  as  only  a  signal  to  the  apothecary  that 
a  prescription  is  to  follow,  —  and  that  such  Latin 
and  English  names  as  are  unmistakable  should  be 
promiscuously  intermingled  as  vernacular,  without 
regard  to  case,  as  if  the  whole  were  Anglicized, — 
and  especially  that  subsequent  directions  should  be 
expressed  in  English. 

Chemistry  and  Physiological  Chemistry,  like  Anat- 
omy, or  like  Surgery  to  the  purely  medical  man, 
though  not  daily  weapons  in  the  combat  with  dis- 
ease, are  yet  an  essential  part  of  a  liberal  medical 
education.  Although  we  may  not  look  to  the 
chemical  philosopher  who  has  invested  a  large  in- 
tellectual capital  in  this  collateral  branch  of  study, 
nor  yet  to  the  zealous  advocate  of  the  expansion  of 
all  human  knowledge,  for  an  impartial  estimate  of 
what  may  be  profitable  to  the  three  years'  medical 
student,  we  must  avow  that  no  intelligent  modern 
practising  physician  can  afford  to  be  ignorant  of 
the  great  principles  which  underlie  this  science.  He 
cannot  be  expected  to  manufacture  Epsom  salts, 
any  more  than  the  modern  disciple  of  Izaak  Walton 
can  be  expected,  as  formerly,  to  make  his  own  rod  ; 
yet  he  must  know  their  capabilities.  The  practical 
chemistry  of  the  physician  will  probably  be  con- 
fined to  a  simple  routine  of  the  microscope  and  test- 


o 


8 


tube,  and  to  breeding  harmony  and  peace  in  long 
prescrijDtions ;  yet  it  may  be  fairly  expected  from 
the  average  student  of  the  present  day.  that  he  shall 
know  sometlihig  of  waste  and  supply,  of  assimila- 
tion and  excretion,  something  of  the  analyzed  prod- 
ucts of  disease,  and,  more  than  this,  that  he  shall 
himself  be  able  to  conduct  a  simple  investigation 
for  their  detection. 

But  it  is  useless  to  the  medical  student  to  know 
that  every  four  grains  of  urea  excreted  correspond 
to  five  tons  hfted  through  one  foot;  and  I  believe, 
farther,  that,  as  surely  as  the  manufacture  of  steel 
is  one  thing  and  the  repairing  of  watches  another, 
so  Chemistr}'  and  Physiological  Chemistry  w^ill 
every  day  be  more  and  more  recognized  as  a 
distinct  branch  of  study,  and  the  results  which 
they  furnish  to  medical  science,  in  the  shape  of 
rules  and  signs  to  identify  disease  and  remedies 
to  arrest  it,  as  another  distinct  line  of  study,  each 
separated  from  the  other  by  the  limited  capacity  of 
the  human  mind,  which  can  grasp  a  part,  but  not 
the  whole,  of  human  knowledge,  by  the  limit  of 
life,  which  is  short,  and  by  the  indefinite  expan- 
sion of  either  of  these  branches  of  study,  which  is 
sufficieut  for  the  best  powers  of  the  average  man 
for  the  whole  of  his  best  years. 

It  is  the  business  of  Chemistry  to  supply  facts  and 
resultant  rules  and  methods,  just  as  much  as  to  sup- 
ply the  chemical  tests  upon  the  shelves,  —  in  de- 
tails, in  packages,  with  directions  for  use,  —  that 
labor  here,  as  elsewhere,  may  be  subdivided  with 
the  progress  of  art. 


39 


It  should  be  borne  in  mind,  that,  strictly  speaking, 
a  practitioner  has  no  more  need  of  knowing  the  ori- 
gin and  mode  of  preparation  of  opium  or  Dover's 
powder  than  of  chloral  or  the  oxalate  of  cerium.  Sir 
Astley  Cooper  and  Sir  Benjamin  Brodie  needed  no 
more  detailed  knowledge  about  their  remedies  than 
Sir  Joshua  Reynolds  and  Turner  about  their  colors. 
The  color-manufacturer  and  chemist  should  supjply 
them,  and  tell  their  properties.  It  is  no  derogation 
to  our  science  to  avow,  that,  when  Physics  or  Chem- 
istry is  invoked  in  aid  of  a  fractured  limb,  or  an  acid 
stomach,  or  of  diabetic  food,  it  is  done,  not  in  vir- 
tue of  a  recondite  study  of  those  abstract  sciences 
by  the  physician,  but  rather  in  virtue  of  a  routine 
application  of  details  long  familiar  to  the  exclusive 
chemist  or  mechanic. 

And  so  of  Experimental  Physiology,  which  leads 
away  from  broad  and  safer  therapeutic  views,  and 
toward  a  local  and  exclusive  action  of  chemistry 
and  cells, —  uncertain  ground  for  students,  for  whom 
the  result  of  large  and  well-attested  medical  ex- 
perience is  here  the  safest  teaching,  and  a  habit 
of  mind  leading  to  experiments  on  patients  the 
most  questionable. 

Mercury,  as  a  prominent  specific,  and  opium,  may, 
perhaps,  be  viewed  as  entering  wedges  of  discovery 
in  therapeutic  science,  so  far  as  it  is  more  2^1'obable 
that  they  act  chemically  upon  material  particles 
than  upon  anything  so  immaterial  as  vitality.  The 
history  of  the  cryptogam  and  the  parasite,  of  skin- 
disease,  the  grape,  the  potato,  the  smut  of  wheat, 


40 


and  the  silk-worm,  also  points  to  the  hypothesis  of  a 
material  cause  of  disease,  of  a  derangement  of  the 
machinery  this  side  of  the  impalpable  or  even  of  the 
mvisible, — to  chemical  combinations  of  remedy  with 
disease,  resulting  in  harmless  products  replacing 
noxious  ones,  or,  in  the  case  of  germ-life,  to  combi- 
nations fatal  to  it.  But  we  may  carry  the  theory 
of  tangible  or  visible  machinery  too  far.  AYhen  the 
philosopher  avers,  that,  because  the  air  is  full  of 
dust,  therefore  some  floating  germ  probably  causes 
cholera  and  scarlatina,  yellow  fever,  plague,  or  ce- 
rebro-spinal  meningitis,  it  should  be  remembered, 
that,  although  we  conventionally  return  to  dust,  we 
do  not  spring  from  dust  alone.  Dust  does  not  make 
monstrosities,  or  cancer,  or  tumors ;  nor  is  inflam- 
mation dust.  It  remains  to  be  shown  whether 
miasm  and  infection  are  often  more  palpable  than 
are  hereditary  gout  or  constipation  in  the  sperma- 
tozoon which  transmits  them.  We  know  nothing 
of  vital  force.  Chemistry  may,  indeed,  create  a 
quasi-protoplasm,  but  it  gives  little  assurance  that 
it  can  do  more  in  this  direction.  The  Pvormalion 
of  modern  Chemistry  may  with  infinite  skill  form 
his  statue,  but  the  proved  facts  of  modern  Science 
promise  little  to  his  prayer  that  it  may  live.  The 
mason  may  construct  a  house,  but  there  is  little 
hope  that  it  will  ever  be  animated  by  an  added 
vitality  even  of  spontaneous  generation,  or  by  life 
begotten  in  other  than  the  usual  way. 

The   attractive    field    of  Physiological  Chemistry 
leads  through  speculations  like  these,  until  it  reaches 


41 


a  point  of  wild  and  fanciful  hypothesis  which  twenty- 
five  years  since  would  have  startled  the  sober  disci- 
ple of  rigid  induction.  The  reaction  of  the  present 
day  is  from  induction  to  theory.  As  the  soil  throws 
out  alternate  crops,  each  springing  from  the  mate- 
rial which  the  last  has  left  behind,  as  the  religion  of 
the  masses  in  the  lapse  of  years  alternates  between 
apathy  and  excitement,  so  does  the  scientific  w^orld, 
tied  down  for  a  long  period  to  the  monotonous  lead 
of  indisputable  fact,  seek  that  liberty  of  the  imagi- 
nation whose  attractiveness  even  Bacon  well  knew 
and  recognized.  Such  theory  has  undisputed  value. 
The  hypothesis  of  minds  like  those  of  Faraday  and 
Huxley  may  represent  a  value  to  science  hardly  to 
be  overestimated.  But  with  the  student  of  medicine, 
whose  time  is  limited,  the  question  must  ever  be  one 
of  its  economical  distribution.  To  the  utilitarian,  dis- 
paragingly asking,  "  What  is  such  hypothesis  good 
for  ? "  Tyndall  replies,  with  Dr.  Johnson,  "  What  is 
the  use  of  babies?"  I  venture  to  answer,  "To  make 
men  in  twenty-one  years."  Light  that  will  become 
fruit  in  twenty-one  years  has  just  that  value,  and 
no  more ;  and  hence  its  pursuit  may  be  a  thriftless 
investment  of  the  medical  student's  time. 

In  this  country  the  question  is,  What  is  the  most 
profitable  investment  of  time,  capital,  and  labor?  — 
and  the  teacher  of  the  art  of  healing  has  no  more 
right  to  employ  the  time  of  the  ignorant  student  dis- 
proportionately in  the  pleasant  and  seductive  paths 
of  laboratory  experimentation,  because  some  of  these 
may  one  day  lead  to  Pathology  or  Therapeutics,  than 


42 


a  guardian  has  to  invest  the  money  of  his  ward  in 
stocks  or  securities  of  equally  uncertain  prospective 
value  to  him. 

How  few  facts  of  immediate  considerable  value  to 
our  race  have  of  late  years  been  extorted  from  the 
dreadful  sufferings  of  dumb  animals,  the  cold-blooded 
cruelties  now  more  and  more  practised  under  the 
authority  of  Science  I 

The  horrors  of  Vivisection  have  supplanted  the 
solemnity,  the  thrilling  fascination,  of  the  old  une- 
therized  operation  upon  the  human  sufferer.  Their 
recorded  phenomena,  stored  away  by  the  physio- 
logical inquisitor  on  dusty  shelves,  are  mostly  of  as 
little  present  value  to  man  as  the  knowledge  of  a 
new  comet  or  of  a  Tungstate  of  Zirconium :  per- 
haps to  be  confuted  the  next  year;  perhaps  to 
remain  as  fixed  truth  of  immediate  value,  —  con- 
temptible, compared  with  the  price  paid  for  it  in 
agony  and  torture. 

For  every  inch  cut  by  one  of  these  experiment- 
ers in  the  quivering  tissues  of  the  helpless  dog  or 
rabbit  or  Guiuea-pig  let  him  insert  a  lancet  one 
eighth  of  an  inch  into  his  own  skin,  and  for  every 
inch  more  he  cuts  let  him  advance  the  lancet  anoth- 
er eighth  of  an  inch,  and  whenever  he  seizes  with 
ragged  forceps  a  nerve  or  spinal  marrow,  the  seat 
of  all  that  is  concentrated  and  exquisite  in  agony, 
or  literally  tears  out  nerves  by  their  roots,  let 
him  cut  only  one  eighth  of  an  inch  further,  and 
he  may  have  some  faint  suggestion  of  the  atrocity 


43 


he  is  perpetrating,  when  the  Guinea-pig  shrieks, 
the  poor  dog  yells,  the  noble  horse  groans  and 
strains,  —  the  heartless  vivisector  perhaps  resenting 
the  struggle  which  annoys  him. 

My  heart  sickens  as  I  recall  the  spectacle  at  Alfort, 
in  former  times,  of  a  wretched  horse,  one  of  many 
hundreds,  broken  with  age,  and  disease  resulting 
from  lifelong  and  honest  devotion  to  man's  service, 
bound  upon  the  floor,  his  skin  scored  with  a  knife 
like  a  gridiron,  his  eyes  and  ears  cut  out,  his  teeth 
pulled,  his  arteries  laid  bare,  his  nerves  exposed  and 
pinched  and  severed,  his  hoofs  pared  to  the  quick, 
and  every  conceivable  and  fiendish  torture  inflicted 
upon  him,  while  he  groaned  and  gasped,  his  life 
carefully  preserved  under  this  continued  and  hellish 
torment,  from  early  morning  until  afternoon,  for  the 
purpose,  as  was  avowed,  of  familiarizing  the  pupil 
with  the  motions  of  the  animal.  This  was  surgical 
vivisection  on  a  little  larger  scale,  and  transcends 
but  little  the  scenes  in  a  physiological  laboratory. 
I  have  heard  it  said  that  "  somebody  must  do  this." 
I  say  it  is  needless.  Nobody  should  do  it.  Watch 
the  students  at  a  vivisection.  It  is  the  blood  and 
suffering,  not  the  science,  that  rivets  their  breathless 
attention.  If  hospital  service  makes  young  students 
less  tender  of  suffering,  vivisection  deadens  their  hu- 
manity and  begets  indifference  to  it. 

In  experiments  upon  the  nervous  system  of  the 
living  animal,  whose  sensibility  must  be  kept  alive, 
not  benumbed  by  the  blessed  influence  of  anaesthe- 
sia, a  prodigal  waste  of  suflering  results  from  the 


44 


difficulty  of  assigning  to  each  experiment  its  precise 
and  proximate  effect.  The  rumpled  feathers  of  a 
pigeon  deprived  of  his  cerebellum  may  indicate 
not  so  much  a  specific  action  of  the  cerebellum  on 
the  skin  as  the  more  probable  fact  that  the  poor  bird 
feels  sick.  The  rotatory  phenomena,  once  consid- 
ered so  curious  a  result  of  the  removal  of  a  cerebral 
lobe,  were  afterwards  suspected  to  proceed  from  the 
struggles  of  the  victim  with  his  reuiaining  undam- 
aged and  unpalsied  side.  Who  can  say  whether- the 
Guinea-pig,  the  pinching  of  whose  carefully  sensi- 
tized neck  throws  him  into  convulsions,  attains  this 
blessed  momentary  respite  of  insensibility  by  an  un- 
explained special  machinery  of  the  nervous  currents, 
or  a  sensibility  too  exquisitely  acute  for  animal  en- 
durance ?  Better  that  I  or  my  friend  should  die 
than  protract  existence  through  accumulated  years 
of  torture  upon  animals  whose  exquisite  suffering 
we  cannot  fail  to  infer,  even  though  they  may  have 
neither  voice  nor  feature  to  express  it. 

If  a  skilfully  constructed  hypothesis  could  be  elab- 
orated up  to  the  point  of  experimental  test  by  the 
most  accomplished  and  successful  philosopher,  and 
if  then  a  single  experiment,  though  cruel,  would  for- 
ever settle  it,  we  might  reluctantly  admit  that  it  was 
justified.  But  the  instincts  of  our  common  humanity 
indignantly  remonstrate  against  the  testing  of  clumsy 
or  unimportant  hypotheses  by  prodigal  experimenta- 
tion, or  making  the  torture  of  animals  an  exhibition 
to  enlarge  a  medical  school,  or  for  the  entertainment 
of  students,  not  one  in  fifty  of  whom  can  turn  it  to 


45 


any  profitable  account.  The  limit  of  such  physio- 
logical experiment,  in  its  utmost  latitude,  should  be 
to  establish  truth  in  the  hands  of  a  skilful  experi- 
menter with  the  greatest  economy  of  suffering,  and 
not  to  demonstrate  it  to  ignorant  classes  and  en- 
courage them  to  repeat  it. 

The  reaction  which  follows  every  excess  will  in 
time  bear  indignantly  upon  this.  Until  then,  it  is 
dreadful  to  think  how  many  poor  animals  will  be 
subjected  to  excruciating  agony,  as  one  medical 
college  after  another  becomes  penetrated  with  the 
idea  that  vivisection  is  a  part  of  modern  teaching, 
and  that,  to  hold  way  with  other  institutions,  they, 
too,  must  have  their  vivisector,  their  mutilated  dogs, 
their  Guinea-pigs,  their  rabbits,  their  chamber  of  tor- 
ture and  of  horrors  to  advertise  as  a  laboratory. 

The  direct  and  efl&cient  medication  open  to  the 
surgeon  contrasts  strongly  with  that  upon  which 
the  physician  leans,  and  which  is  grounded  on 
the  uncertain  indications  furnished  by  pulse  and 
tongue,  temperature  and  digestion.  His  therapeu- 
tic armamentarium  compares  still  more  strikingly 
with  the  limited  remedial  resources  of  medical  art. 

The  practitioner  recognized  as  a  surgeon,  because 
he  professes  a  knowledge  of  surgical  lesion  and  dis- 
ease, or  because  he  has  popularly  identified  himself 
with  the  far  inferior  province  of  Operative  Surgery, 
can  indeed  do  little,  compared  w^th  the  great  recu- 
perative force  of  vitality  in  its  silent  and  never  ceas- 
ing work  among  the  atoms,  establishing  the  cell  out- 


46 


posts  of  a  new  territory,  and  collecting  and  manu- 
facturing the  raw  material  into  the  completed  tissue, 
until  the  work  of  repair  is  perfect.  Compared  with 
this,  it  is  poor  skill  which  cuts  off  a  tumor  or  a  leg, 
lays  a  fractured  limb  straight,  replaces  the  fragments 
of  a  broken  joint,  —  or  that  fails  to  do  so.  Yet 
nowhere  has  medical  art  conquered  so  large  a  do- 
main as  in  surgery,  nowhere  is  progress  so  rapid, 
and  nowhere  is  the  importance  of  principles  so  forci- 
bly presented  to  the  student.  Such  principles  lead 
back  to  precise  rules.  Thus,  if  a  common  ulcer,  in 
default  of  local  cause,  is  treated  according  to  its 
condition,  by  stimulant  or  soothing  measures,  here 
are  principles ;  and  if  the  student  is  acquainted  with 
measures,  he  at  once  commands  all  the  resources  of 
his  art.  Without  these  principles,  he  perhaps  applies 
a  '^wash,''  with  the  simple  faith  which  leads  him  to 
rub  mercurial  ointment  on  every  induration.  Such 
views  hold  generally  true  of  surgery,  which  deals 
largely  with  mechanics  and  surface-work,  and  there- 
fore admits  of  much  precise  knowledge,  susceptible 
of  a  generalization  of  highest  value  to  the  student. 

In  this  connection,  and  as  still  allotted  to  the  sur- 
ofeon,  we  should  not  foro:et  the  mascnificent  and 
practical  studies,  fresh  with  the  imprint  of  modern 
discovery.  Inflammation  and  Repair,  where  the  vital 
principle,  stimulated  by  emergency,  exhibits  at  the 
will  of  the  observer  so  rapid  and  comprehensive  a 
panorama  of  the  processes  of  healthy  nutrition. 

Much  abused  as  it  is,  I  sometimes  think  that  a 
wholesome  fear  of  the  law  of  the  land  is  not  a  bad 


47 


stimulus  to  well-doing  in  surgery.  The  medical 
man  becomes  so  accustomed  to  standing  by,  with 
the  solemn  conventionalism,  the  routine  and  imple- 
ments and  parade  of  art,  and  so  accustomed  to  the 
familiar  fact  that  medical  disease  pursues  its  un- 
abated and  independent  course  in  spite  of  what 
he  does,  or  so  sure,  at  any  rate,  that  nobody,  not 
even  he  himself,  will  know  the  difference,  that  he 
gets  insensibly  to  feel,  that,  if  he  does  the  best  he 
can  in  surgery,  nobody  will  know  the  difference  in 
surgical  result.  But  everybody  professes  an  opinion 
on  a  distorted  limb.  Many  medical  lesions  can  wait 
until  the  practitioner,  like  a  lawyer,  refreshes  his 
knowledge  ;  but  broken  thighs  and  elbows,  wrists 
and  ankles,  will  not  wait,  and  every  physician  should 
know  how  to  treat  what  is  so  liable  to  bad  treat- 
ment. 

Lastly,  I  believe  that  much  of  Medical  Jurispru- 
dence, so  called,  a  subject  which  treats  of  the  legal 
relations  of  medicine  and  of  the  medical  man,  is 
probably  better  allotted,  in  instruction,  to  the  special 
department  which  it  touches,  as  I  am  sure  so  much 
of  it  as  relates  to  surgery  is,  —  and  that  the  quali- 
ties of  a  good  witness,  sometimes  discussed  in  lec- 
tures upon  this  subject,  are,  like  those  of  a  poet, 
rather  congenital  than  to  be  acquired. 

In  thus  briefly  glancing  at  the  education  of  the 
practitioner,  let  us  not  overlook  the  wants  of  an- 
other class,  who,  from  natural  capacity,  or  power  of 


48 


application,  or  from  preliminary  opportunities  and 
training,  can  avail  themselves  of  the  advantages  of 
a  larger  education,  —  who  desire  to  leave  the  level 
plain  of  practical  study,  and  climb  the  neighboring 
and  lofty  heights  of  Science,  upon  whose  rills  it  de- 
pends for  its  fertility.  In  these  days,  an  aspiration 
toward  something  more  or  higher  than  routine,  a 
desire  to  transmit  to  Science,  even  in  a  humble  way, 
some  return  for  what  Science  has  bestowed,  a  wash 
to  breathe  awhile  in  the  clear  atmosphere  of  the 
sciences  which  contribute  to  the  progress  of  medi- 
cine, are  fortunately  common.  It  need  not  be  said 
that  a  medical  school  should,  if  it  can,  meet  this 
generous  demand  for  learning  wdth  large  and  ample 
opportunities ;  in  doing  so,  however,  it  should  not 
lose  sight  of  its  legitimate  purpose,  the  education  of 
medical  practitioners,  nor  lure  the  medical  student 
away  from  essential  study,  still  less  exact,  by  ex- 
amination, from  the  future  practitioner,  in  favor  of 
the  scientist,  a  disproportionate  amount  of  less 
applicable  knowledge,  —  propositions  upon  which  I 
strenuously  insist. 

Here  I  may  call  your  attention  to  the  fact  that 
the  student  of  the  collateral  medical  sciences  is  not 
always  the  first  in  the  field  of  great  medical  dis- 
covery. 

It  is  a  generous  and  pardonable  sentiment  w^iich 
would  claim  for  high  and  abstract  Science  a  large 
share  in  discoveries  of  great  immediate  utility.  But 
medical  discovery  is  generally  not  made  by  workers 


49 


in  chemical  and  physiological  fields,  but  by  subse- 
quent and  more  purely  medical  observers,  who  apply 
to  disease  the  materials  and  results  of  such  previous 
work.  Abstract  Science  crawls  with  snail's  pace  and 
amoeboid  reach,  letting  in  here  and  there  a  little 
light,  gathering  up  everything  new,  true,  or  proba- 
ble, whether  immediately  applicable  or  for  the  time 
useless,  so  far  as  any  obvious  application  of  it  goes  : 
thus  slowly  filling  storehouses  with  goods  of  every 
kind,  from  priceless  gems  to  worthless  rubbish.  The 
practical  man  goes  there  to  seek  something  for  his 
purpose,  and  takes  from  the  shelves  the  electric  ap- 
paratus for  his  telegraph,  lunar  caustic  for  his  pho- 
tograph, ether  for  anaesthesia,  the  sugar  tests  and 
the  food  for  diabetes.  We  justly  honor  the  patient 
and  learned  worker  in  the  remote  and  exact  sciences, 
but  should  not  for  that  reason  encourage  the  medi- 
cal student  to  while  away  his  time  in  the  labyrinths 
of  Chemistry  and  Physiology,  when  he  ought  to  be 
learning  the  difference  between  hernia  and  hydro- 
cele. Let  him  go  to  the  storehouse,  and  get  his 
clothes,  his  coals,  and  his  remedies,  without  being 
compelled  to  study  tailoring,  or  Geology,  or  the 
manufacture  of  quinine. 

If  there  is  a  sure  advance  in  the  slow  siege- 
approaches  of  the  scientist,  a 'sure  progress  by  the 
pick  and  shovel  for  succeeding  generations,  there  is 
also  another  progress  growing  out  of  this,  which  re- 
sults from  the  coup  of  impetuous  force,  or  the  strat- 
egy of  genius.  An  able  writer  has  said  that  "the 
most  original  and   important  inventions   the  world 


50 


has  ever  seen  were  the  productions  of  men  who  had 
received  Httle  or  no  previous  training  in  the  partic- 
ular art  they  have  sought  to  improve."  A  large 
part  of  that  successful  therapeutics  which  is  the  ulti- 
matum of  medical  science  results  from  such  original 
and  not  profound  experiment.  A  member  of  this 
Society,  having,  a  quarter  of  a  century  ago,  vainly 
treated  a  case*  of  virulent  eczema,  considered  what, 
as  likely  to  do  it  least  good,  had  been  carefully 
shunned  by  previous  practitioners,  and  applied  to 
the  excoriated  surface  an  active  stimulant,  which 
not  only  cured  it.  but  has  since  proved  a  scientific 
remedy  of  modern  progress. 

We  owe  the  compass,  the  printing-press,  the  tel- 
egraph, vaccination,  and  anesthesia  —  light-houses 
and  fortresses  of  human  hapj^iness,  safety,  and  knowl- 
edge —  indirectly  to  abstract  Science,  and  directly 
to  practical  working  men.  Art  is  the  scientific  ap- 
plication of  the  more  accurate  and  positive  part  of 
human  knowledge.  It  is  this  which  the  student  of 
medical  science  needs,  call  it  by  what  name  you 
please.  "  One  of  the  enormous  follies  of  the  enor- 
mously foolish  education  of  England,"  says  Sydney 
Smith,  in  a  familiar  passage,  "is,  that  all  young 
men,  dukes,  fox-hunters,  and  merchants,  are  edu- 
cated as  if  they  were"  to  keep  a  school  or  serve  a 
curac}^"  With  equal  force  it  may  be  said  that  it 
is  not  necessary  to  educate  the  family  practitioners 
of  town  or  country  as  if  they  were  to  serve  in  lab- 
oratories, and  make  analyses  of  biliverdin  or  uro- 
ervthrine. 


51 


The  great  object  of  modern  education  is  to  ascer- 
tain what  the  student  wants,  and  to  supply  it  exactly 
to  his  mind  in  the  surest  and  shortest  way.  If,  there- 
fore, he  asks  to  be  taught  fishes,  do  not  teach  him 
stones  ;  if  he  desires  a  good  English  education,  do  not 
compel  him  first  to  learn  Latin  and  Greek;  if  he 
wants  to  identify  fevers  and  fractures,  do  not  engross 
his  time  with  cell  theories  and  hydrocarbons. 

The  medical  student  does  not  need  to  pick  herbs 
from  the  field,  or  treat  horses  and  dogs,  or  consider 
his  parallelogram  of  forces  before  pulling  in  a  dis- 
located shoulder ;  but  he  does  need  to  know  how 
to  recognize  and  exactly  how  to  reduce  a  dislocated 
shoulder,  how  to  recognize  and  treat  human  disease, 
and  what  are  the  medical  properties  of  the  drug  which 
the  farmer  has  grown  or  the  merchant  imported  for 
the  apothecary.  This  is  but  a  fair  division  of  labor. 
He  has  enough  to  occupy  him  profitably  and  exclu- 
sively in  his  own  immediate  field  of  study,  without 
wandering  over  the  whole  domain  of  knowledge,  — 
at  least  at  the  mistaken  behest  of  those  who  have  a 
confused  notion  of  a  liberal  education  and  large  cul- 
ture, and  whose  chief  motive  for  sending  the  unfor- 
tunate student  to  explore  new  territory  seems  to  be 
that  they  have  themselves  invested  capital  there. 

If  we  may  fairly  assume,  on  the  one  hand,  that 
few  undergraduates  need  to  calculate  the  curves  of 
a  turbine  wheel,  we  may  equally  aftirm  that  the 
mechanism  of  the  steam-engine,  and  of  a  hundred 
other  engines,  as  of  that  magnificent  creation  of 
American  intellect,  the   three-ply  carpet  loom,  for 


52 


years  in  large  and  profitable  use  at  Lawrence,  and 
yet  so  complicated  that  the  Englishman  has  never 
been  able  to  introduce  and  run  it,  —  that  study  of 
this  sort  would  afford  a  profitable  field  for  the  exer- 
cise of  the  hit^her  faculties  of  analysis  and  combina- 
tion.  Yet  the  undergraduate  of  my  day,  who  was 
seduced  by  the  name  Mechanics  into  cheerfully 
beginning  an  octavo  which  he  fondly  hoped  treated 
of  pumps  and  pulleys,  which  he  could  understand, 
found  at  the  end  of  half  a  dozen  pages  that  each 
part  of  a  pump  or  pulley  was  replaced  by  a  letter 
or  a  numeral,  and  that  the  next  three  months  of 
his  life  were  to  be  eno;rossed  in  lUG^o'lino;  these 
signs  and  symbols,  like  cups-and-balls,  or  bobbins  on 
a  cushion,  as  numerators  and  denominators,  above 
lines  and  below  lines,  on  one  side  of  an  equation  or 
on  the  other  side,  with  no  single  idea  attached  to 
them,  at  least  of  anything  that  is  on  the  earth  or  in 
the  water,  —  until,  at  the  end  of  three  breathless 
and  harassing  months,  the  symbols  were  again  con- 
verted, to  his  great  relief,  into  familiar  pumps  and 
pulleys,  although  with  no  new  or  distinct  idea  add- 
ed. This  was  Science,  not  Art,  —  and  Mathematics, 
not  Mechanics.  Mathematics  deal  with  abstract 
quantity:  our  art  deals  with  material.  Like  chess- 
playing,  the  mathematical  faculty  is  not  the  high- 
est or  most  profitable  quality  of  inventive  mind,  in 
mechanical  or  other  arts,  or  even  in  life ;  yet  the 
conviction  of  this  day  and  community  inclines  a  lit- 
tle to  the  view  that  a  medical  practitioner  who  is 
fitting  a  presbyopic  friend  with  spectacles,  without 


53 


at  the  same  time  explaining  to  him  that  ^  =  J  —  J 
does  not  quite  rise  to  the  emergency.  And  this 
criticism  involves  neither  disrespect  nor  ingratitude 
to  any  philosopher  whose  exclusive  learning  has  so 
prepared  the  inorganic  elements  of  our  science  that 
they  can  be  readily  assimilated  and  digested  by  the 
student  of  our  art,  and  made  available,  whether  for 
medical  practice  or  medical  discovery. 

There  is  a  fallacy  in  the  idea  of  culture.  A  man 
accomplished  in  one  direction  is  not  necessarily  ed- 
ucated in  another.  High  a3sthetic  culture  did  not 
prevent  the  distinguished  French  painter  and  his 
friends  from  superintending  the  destruction  of  the 
Column  of  the  Place  Vendome.  The  humanizing 
influences  of  refined  beauty  in  Art  neither  taught 
them  to  restrain  their  personal  and  political  hate, 
npr 

"with  sweet  science  mollified  their  stubborn  hearts." 

Talent  and  power  of  application  may,  indeed,  inci- 
dentally lead  a  man  to  eminence  in  several  directions. 
But  a  cultivated,  a  literary,  or  even  a  scientific  man 
is  not  necessarily  the  best  physician  :  the  best  phy- 
sicians, indeed,  are  sometimes  possessed  of  little  out- 
side culture.  The  same  is  true  of  other  pursuits. 
The  obvious  inference  is,  that  the  most  valuable 
knowledge  is  that  which  is  most  applicable  to  the 
purpose  in  view. 

The  great  and  immediate  cause  of  Prussian  success 
in  the  late  contest  with  France  was  proficiency  in  the 
science  and  art  of  War.     That  the  Prussian  govern- 


54 


ment  had  better  material  to  Trork  with,  that  the 
whole  body  of  the  people  was  educated  up  to  a  level 
which  enabled  tlieui  to  learn  more  readily  and  com- 
pletely the  business  of  the  soldier,  and  generated,  if 
you  please,  a  higher  sense  of  military  duty,  was  of 
course  so  much  the  better  for  them.  But  this  was  a 
question  of  preliminary  and  early  education.  We 
may  rely  upon  it,  that,  when  war  came,  the  highly 
educated  and  intelligent  Prussian  officers  set  their 
soldiers,  whoever  they  were,  and  whatever  they 
knew,  to  reviewing,  not  politics,  nor  philosophy, 
nor  yet  reading  and  writing,  but  organization,  dis- 
cipline, and  drill.  This  had  been  a  part  of  every 
man's  education,  and  this  explains  their  success. 

Even  in  an  atmosphere  and  country  which  encour- 
age intellectual  growth  and  expansion,  the  average 
condition  of  society  is  advanced  onl}'  so  far  as  each 
individual  advances  his  province  and  department  of 

it.     Therefore,  if  he  is  to  learn  '-a  little  of  everv- 

-  •/ 

thing,"  let  us  be  sure  that  he  learns  "  a  great  deal 
of  something,"  —  of  that  which  is  to  him  most  im- 
portant. 

In  these  days  of  arms  of  precision,  if  we  elevate 
the  aim  and  increase  the  range,  whether  in  gunnery 
or  education,  we  are  compelled  to  adjust  the  sight 
more  accurately  to  the  object.  Let  us  have  liberal 
education  in  its  widest  sense,  the  highest  educa- 
tion possible  to  the  whole  mind  and  the  whole 
body  of  the  largest  number  everywhere,  —  but 
then  let  us  beu'in  at  the  beo-inninti:  and  teach  the 
child,  and  not  at  the  end  ;  and  when  the  medical 


65 


student  comes  to  you  with  three  scant  years  which 
you  cannot  extend,  and  preHminary  acquirements 
which  you  cannot  then  increase,  —  small  capital 
enough  for  the  study  of  human  disease  in  all  its 
modern  interpretation,  —  do  not  send  him  wool- 
gathering among  the  abstract  and  collateral  sci- 
ences. 

Mathematics,  Physics,  Botany,  Comparative  Anat- 
omy, Physiology,  Chemistry,  as  subjects  of  study,  are 
all  secondary  to  those  essential  and  limited  parts  of 
each  of  these  collateral  sciences,  whether  principles 
or  details,  which  have  been  actually  applied  to 
medical  diagnosis  and  therapeutics,  —  secondary,  in 
short,  to  the  study  of  medical  science,  and  especially 
of  medical  art. 

In  giving  this  utterance  to  what  a  friend  of  mine 
was  once  pleased  to  denounce  as  scientific  blasphe- 
my, in  assigning  a  limit  to  the  present  utility  of  cer- 
tain branches  of  science  in  medical  education,  I 
do  not  propose  a  barrier  to  the  progress  of  human 
knowledge,  but  insist  that  less  applicable  science 
should  not  be  confounded  with  medical  art,  what 
the  student  may  or  may  not  need  with  what  he 
must  have. 

Let  me  advert  to  a  drier,  but  not  less  important 
subject :  I  mean  the  machinery  of  teaching.  We 
shall  presently  see  that  the  European,  especially  the 
German  University,  administered  and  directed  by  the 
Government,  has  in  consequence  great  advantage  in 
exercising  a  monopoly  of  medical  teaching,   and  in 


66 


thus  compelling  the  student  to  support  and  encour- 
age a  single  and  best  system.  I  need  not  say  that 
such  an  arrangement  is  impossible  in  this  country, 
where  State  governments  grant  medical  charters 
without  stint,  to  all  forms  of  professed  medical  faith. 
However  desirable  in  theory  a  central  guiding  pow- 
er in  medical  education,  in  this  republican  country 
we  have  neither  got  nor  can  we  have  one. 

There  exists,  no  doubt,  an  eagerness  to  assume  and 
exercise  such  power.  The  American  Medical  Asso- 
ciation, for  example,  passed,  only  a  year  ago,  the 
following  vote :  — 

"  Resolved,  That  the  American  Medical  Association  has  the 
power  to  control  the  subject  of  Medical  Education  in  the  United 
States,  and  the  power  to  exercise  that  control  in  any  manner  upon 
which  it  may  be  agreed."  * 

I  have  even  heard  it  alleged,  that,  if  a  body  sends 
delegates  to  the  American  Medical  Association,  who 
subscribe  to  its  code  of  ethics,  the  delegating  body 
is  considered  bound  by  that  code.  This  groundless 
assumption  is  the  only  claim  which  the  American 
Medical  Association,  so  called,  possesses  to  authority 
over  the  medical  societies  or  the  medical  schools. 

The  Massachusetts  Medical  Society  is  a  corpora- 
tion with  no  power  except  that  which  it  derives 
from  its  charter,  and  under  this  charter  it  must 
act  as  other  corporations  do,  by  the  votes  of  its 
members  at  legal  meetings,  and  of  its  officers  with- 
in the  scope  of  their  authority.  It  cannot  delegate 
to  another  corporation,  or  to  a  voluntary  association, 

*  Trans.  Am.  Med.  As^oc  ,  1870,  V..1.  XXI.  p.  35. 


57 


the  power  to  make  its  by-laws,  or  to  prescribe  rules 
for  its  action.  If  its  members  choose  to  obey  the 
rules  of  any  other  association  or  corporation,  it  is 
their  individual  act,  and  not  the  act  of  the  Massa- 
chusetts Medical  Society;  and  no  such  action  on 
their  part  can  bind  it,  until  it  is  ratified  by  the 
Society.  The  same  remarks  are  especially  true  of 
the  medical  schools. 

The  American  Medical  Association  is  a  body  of 
medical  gentlemen,  practically  volunteer  delegates, 
having  primarily  in  view  the  agreeable  and  com- 
mendable object  of  a  journey  to  break  the  monotony 
of  medical  practice  and  give  them  an  apology  for 
leaving  their  homes  and  their  patients  at  a  pleasant 
season  of  the  year.  Tlie}^  assemble  to  revive  old 
friendships,  to  form  new  acquaintances,  to  make  ex- 
cursions, and  to  settle  down  into  relations  of  o-ood 
fellowship,  after  a  healthy  difference  of  opinion  over 
current  medical  topics  and  parliamentary  forms. 
There  are  among  them  members  who  take  an  active 
and  intelligent  interest  in  the  cause  of  medical  sci- 
ence, its  progress,  and  its  teaching;  but  they  can 
exercise  little  influence  except  in  suggesting  what 
may  seem  to  them  desirable. 

We  must  not  be  startled,  if  so  extemporaneous  an 
assemblage,  while  united  in  the  semblance  of  parlia- 
mentary organization,  and  before  they  have  settled 
down  into  that  harmonious  and  neighborly  cordiality 
which  is  their  ultimate  object,  should  pronounce  im- 
mature opinions,  claim  for  themselves  authority,  and 
hastily  denounce  friends,  or  even  issue  bulls  of  ex- 


58 


communication  of  as  portentous  form  and  as  little 
significance  as  the  tail  of  a  comet,  which  may  over- 
cast the  whole  country  with  its  shadow,  but  which 
astronomers  assure  us  may  be  carried  in  a  man's  hat. 
It  is  not  surprising  that  they  should  virtually  say 
to  you,  a  State  society,  empowered  by  your  Legisla- 
ture merely  to  exact  from  each  member  a  certain 
quantity  and  quality  of  knowledge,  that,  if  you  do 
not  transcend  your  legal  authority  and  inquire  into 
any  other  knowledge  he  may  possess,  in  a  way 
not  only  unauthorized  by  the  law  of  the  State,  but 
which  its  lawgivers  would  forbid,  then  they,  the 
Association,  will  neither  let  you  eat  their  dinners, 
join  their  harbor-excursions,  nor  participate  in  their 
discussions,  —  nor  will  they  allow  you  to  use  the 
platform  and  the  name  of  the  Association  to  venti- 
late your  private  or  political  differences. 

This  Society,  the  medical  schools,  and  the  medical 
community  can  well  afford  to  attach  little  impor- 
tance to  such  of  the  doings  of  the  American  Medical 
Association  as  seem  skilfully  designed,  under  the 
specious  pretext  of  setting  things  right,  to  set  men 
wrong.  A  body  of  so  uncertain  temper  and  impul- 
sive action  obviously  has  no  authority  to  express 
even  public  medical  opinion. 

The  number  of  medical  schools  in  this  country 
being  practically  unlimited,  each  school  is  liable  to  be 
successfully  underbid,  whether  in  fees  or  educational 
standard,  by  its  neighbors,  so  long  as  a  chief  object 
of  the  large  majority  of  students  is  the  medical  de- 
gree which  confers  authority  to  practise. 


59 


Most  American  medical  colleges  are  virtually  close 
corporations,  which,  under  a  Board  of  Trustees,  in 
whom  the  power  is  legally  vested,  are  really  admin- 
istered by  their  professors,  who  receive  the  students' 
fees,  and  upon  whose  tact  and  ability  the  success 
of  these  institutions  wholly  depends. 

A  University  possesses  over  all  its  departments 
a  legal  jurisdiction;  but  it  may  be  a  question  of 
expediency  how  far  this  shall  be  enforced. 

The  general  supervision  of  a  medical  college  by 
a  University  has,  indeed,  certain  advantages.  It 
may  insure  activity  in  the  teaching,  and,  if  exercised 
with  constant  reference  to  the  possibility  of  thereby 
inducing  change  for  the  better,  be  thus  an  antidote 
to  excessive  conservatism. 

Such  wise  direction  from  outside  may  perhaps  ad- 
vantageously share  equally,  but  no  further,  the  duty 
of  seeking  candidates  for  the  offices,  and  of  sifting 
their  qualifications,  —  and  while  it  thus  assists  them 
to  enter  the  school,  may  influence  them  also  to  leave 
it,  should  their  teaching  prove  notoriously  inade- 
quate. It  may  stand  between  the  school  and  the 
community,  especially  the  medical  community,  in 
satisfying  them  of  the  impartial  character  of  ap- 
jDointments,  the  conscientious  labor  of  incumbents, 
and  their  devotion  to  the  best  interests  of  educa- 
tion. It  may  satisfy  the  public  that  the  questions 
of  the  day,  having  a  direct  relation  to  the  best 
methods  of  teaching,  have  received  careful  atten- 
tion,—  in  short,  that  the  first  object  of  the  school 
is  the  welfare  of  the  students  and  the  elevation  of 


60 


true  medical  science,  and  not  the  emolument,  direct 
or  professional,  of  the  instructors. 

But  medical  teaching;  should  not  be  too  much  in- 
terfered  with,  nor  its  machinery  hampered  by  those 
Avho  are  not  familiar  with  its  working. 

A  large  part  of  medical  teaching  —  perhaps,  on 
the  whole,  the  most  important  part  —  is  the  clin- 
ical instruction  of  hospitals,  which  it  is  quite  plain 
can  never  be,  in  this  country,  as  in  Germany,  in  any 
way  within  the  jurisdiction  of  a  University.  Again, 
a  University,  apart  from  its  medical  teachervS,  can 
know  little  or  nothing  of  the  complicated  lines  of 
division  between  medical  subjects,  or  of  their  rela- 
tive importance,  upon  which  depends  the  establish- 
ment of  professorships  and  other  offices. 

But  another  consideration  lies  deeper.  A  Uni- 
versity cannot  judge  accurately  of  medical  men,  in 
a  community  where  solid  scientific  eminence  and 
mere  notoriety  in  practice  are  largely  confounded. 
While  in  France  and  Germany,  as  we  shall  present- 
ly see,  the  scientific  merits  of  candidates  for  the 
higher  places  are  publicly  sifted  and  proclaimed, 
no  such  system  prevails  or  can  find  place  here ; 
and  while  abroad  it  is  well  understood  that  in 
medicine  the  most  popular  teaching  may  not  be 
the  most  profitable  to  the  student,  in  this  country 
professional  distinction  is  often  of  uncertain  char- 
acter, and  you  may  readily  mistake  in  the  teacher 
eloquence  or  an}^  other  attractive  quality  or  accom- 
plishment for  science.  If  you  add  that  in  this 
country  medical  teaching  is  generally  esteemed,  not. 


61 


as  in  Germany^  in  itself  an  end,  but  a  means,  a 
road  to  the  medical  practice  which  is  here  the  ul- 
timatum of  every  medical  man,  you  subject  your 
University  authorities  to  outside  pressure  for  place 
and  preferment,  which  they  may  be  equally  unquali- 
fied to  judge  of  and  unable  or  disinclined  to  resist. 

The  policy  of  enlarging  a  faculty  by  an  indis- 
criminate addition  of  professors  might  grow  out  of 
an  erroneous  belief  that  you  can  teach  medical  facts 
from  books  by  acceptable  tutors,  as  you  can  Greek 
or  Physics.  The  reverse  is  notoriously  true.  The 
teacher  of  the  higher  medical  branches  must  filter, 
digest,  and  recast  book  facts,  to  a  degree  that  im- 
plies large  actual  experience  and  sound  judgment. 

For  these  reasons  alone,  while  formal  appointments 
may  be  better  left  to  the  University,  I  am  satisfied 
that  nominations,  as  in  Germany,  should  be  formally, 
at  any  rate  practically,  delegated  to  a  faculty  of 
medical  men.  And  the  same  is  true  of  the  estab- 
lishment of  professorships,  and  of  the  general  organ- 
ization of  the  school. 

In  medical  matters,  a  University  should  rely 
largely  upon  the  guidance  and  wisdom  of  those  to 
whom  it  does  not  scruple  to  intrust  its  teaching.  It 
may  well  hesitate  to  ignore  their  advice,  and  assume 
more  than  a  general  supervision  over  machinery 
which  has  a  complicated  relation  to  the  medical 
community,  and  especially  to  the  rest  of  medical 
teaching  throughout  the  country,  of  which  but  a 
small  part  is  connected  with  Universities,  —  a  ma- 
chinery whicli,   to  insure  success,  must   be   largely 


62 


an  anomaly  in  its  relations,  its  rules,  and  its  offices, 
when  compared  with  other  departments  of  a  Uni- 
versity. 

If  a  University  desires  to  secure  the  services  of 
medical  men  of  competence  or  eminence,  most  of 
whom,  in  this  country,  unlike  teachers  of  under- 
graduates, are  engaged  in  active  business,  it  will 
maturely  weigh  the  question,  how  it  may  compen- 
sate them,  —  whether  by  professorial  position,  which, 
if  you  make  it  common  and  cheap,  ceases  to  be 
desirable,  —  by  intrusting  them  with  discretion  and 
authority,  which,  if  you  reduce  them  to  the  rank- 
and-file  of  tutors,  and  rule  them  by  a  non-medical 
and  comparatively  uninstructed  interference,  they 
no  longer  possess,  —  or  by  money,  which  in  the 
higher  branches  of  medical  teaching,  and  in  de- 
fault of  other  inducements,  must  be  considerable 
in  amount. 

German  medical  science,  until  fifty  years  ago  in- 
fused with  German  mysticism,  with  a  priori  specu- 
lation concerning;  remote  affinities,  inauofurated  about 
that  time  a  different  philosophy,  substituting  for 
theory  and  vain  discussion  rigorous  deduction  from 
ascertained  facts,  —  the  method,  in  short,  so  long  be- 
fore vindicated  by  Lord  Bacon.  Soemmerring  and 
Meckel  in  Anatomy,  and  Burdach  and  others  in 
Physiology,  were  now  laying  the  foundation  of  a 
school  of  exact  observation  in  medical  science. 
About  this  period,  also,  Laennec  was  a  prominent 
pioneer  of  an  equally  exact  school  in  France,  des- 


63 


lined  to  eclipse  for  a  time,  by  the  labors  of  men 
with  whose  names  this  community  are  famihar,  the 
slower,  but  solid,  progress  of  the  German  school. 
But  the  superiority  then  and  for  years  afterward 
so  obvious  in  French  medical  science,  and  to 
whose  valuable  teaching  the  German  school  owes 
much,  has  gradually  yielded  to  the  rapid  strides  of 
more  recent  German  progress.  The  learned  and 
distinguished  Johann  Midler,  the  father  of  Exact 
Physiology,  soon  followed  by  Schwann,  Henle,  Lie- 
big,  Rokitanski,  Valentin,  and  Weber,  and  later  by  a 
host  of  others,  of  world-wide  reputation,  inculcated 
both  by  teaching  and  practice  the  value  of  accurate 
experiment,  to  the  exclusion  of  unproved  theory,  — 
a  line  of  study  rigorously  prosecuted  for  the  last 
quarter  of  a  century. 

The  barren  fields  of  speculative  hypothesis  and 
arbitrary  assertion  have  thus  been  fairly  replaced  by 
the  precise  results  of  induction  from  observed  phe- 
nomena ;  and  when  we  consider  the  multitude  of 
able  minds  and  the  vast  labor  thus  for  years  con- 
centrated upon  the  facts  of  health  and  disease, 
we  shall  be  astonished  neither  at  the  amount  nor 
the  character  of  the  progress  of  medical  science  in 
Germany  during  this  period,  nor  at  the  advantages 
which  the  German  schools  offer  at  this  moment  to 
the  medical  student. 

It  may  be  of  interest  at  this  point  to  allude 
briefly  to  the  so-called  materialistic  tendencies 
w^hich   are    supposed   to   have   grown   out  of  these 


64 


investigations,  and  which  would  have  less  impor- 
tance, were  it  not  for  the  prominence  which  the  nar- 
rower theologians  have  given  to  them  by  active 
opposition.  It  could  hardly  be  supposed  that  the 
German  mind,  with  its  well-known  tendency  to 
theorize,  would  rest  completely  satisfied  with  the 
slow  deductions  authorized  by  facts.  But,  curiously 
enough,  the  theorizing  tendency,  which  before  con- 
structed its  hypotheses  with  little  or  no  foundation, 
now  uses  the  facts  of  modern  science  as  a  basis  for 
similar  hypotheses.  Instead  of  arguing,  for  example, 
upon  the  relation  of  life  to  imaginary  conditions 
of  oscillation  or  tension,  it  has  propounded  ques- 
tions equally  impossible  of  solution  upon  the  recog- 
nized facts  of  Physiology  and  Chemistry.  Thus,  it 
being  clear  that  organized  bodies  have  some  prop- 
erties and  modes  of  action  —  life,  for  example  —  by 
which  they  differ  from  inorganic  bodies,  we  natural- 
ly ask  whether  life  is  a  principle  superadded  to  the 
materiah  The  philosopher  replies :  No,  it  is  not 
necessary  that  a  quality  which  we  find  in  a  body 
should  be  added  to  it,  and  be  distinct  from  it :  for 
example,  the  extension  and  weight  of  a  body  are 
intrinsic  to  it  and  inseparable  from  it ;  we  cannot 
conceive  of  such  qualities  apart  from  the  body  it- 
self: and  so  it  is  with  those  elementary  qualities  of 
organized  bodies  wbose  aggregation  constitutes  life  : 
in  short,  life  is  identified  with  an  organized  body, 
just  as  are  its  size  and  weight.  The  gist  of  this 
argument,  that  vitality  has  no  existence  separate 
from   matter,  is,  that   vitality  separated   from  mat- 


65 


ter  has  never  been  observed  by  human  sense :  it  is 
a  quality  of  matter,  because  we  cannot  put  our  fin- 
ger upon  it  after  it  is  separated  from  matter.  The 
advocate  of  this  doctrine  leaves  no  ground  for  in- 
ference, and  admits  the  existence  of  nothing  which 
has  not  been  observed  by  his  senses.  The  tendency 
of  this  doctrine  is  obvious.  It  leads  to  the  convic- 
tion that  what  we  cannot  observe  apart  from  matter 
does  not  exist,  —  that  there  is  no  weight  or  dimen- 
sion separate  from  matter,  no  vitality  apart  from 
organized  material,  no  thought  apart  from  the  brain 
cell. 

Such  is  Materialism,  the  bugbear  of  theologians. 
Moleschott,  in  1857,  says:  "By  the  very  fact  of  life, 
plants  and  animals  return  to  their  source.  All  is 
resolved  into  ammonia,  carbonic  acid,  water,  and 
salts.  A  bottle  containing  carbonate  of  ammonia, 
chloride  of  potassium,  and  phosphate  of  soda,  with 
lime  and  magnesia,  with  iron,  sulphuric  acid,  and 
silex :  here  is  the  defunct  vital  spark  of  plants  and 
animals."  * 

Such  is  the  position  with  which  Huxley  has  so 
stirred  the  theologians.  Because  protoplasm,  which 
he  assumes  to  be  the  lowest  form  or  basis  of  organ- 
ized life,  is  resolvable  into  ammonia,  etc.,  and  because 
life  has  never  been  observed  by  our  senses  apart  from 
protoplasm,  therefore  life  is  not  something  added  to 
protoplasm,  but  merely  a  quality  of  it,  whose  exist- 
ence  ceases  with   it.     We   have  here  only  time  to 

*  The  Circulation  of  Life  :   Pliysiologifal  Answers  to  Liebiij's  Letters 
on  Chemistry,  by  Jacob  Moleschott,  3d  Edition,  Mayence,  1857,  p.  276. 


66 


answer,  that,  although  we  may  observe  no  Ufe  with- 
out its  protoplasm,  yet  we  may  kill  the  protoplasm, 
and  thus  separate  it  from  life,  while  w^e  cannot  sepa- 
rate matter  from  extension  or  weight. 

It  will  be  readily  seen  that  all  this  leads  through 
a  show  of  chemicals  to  the  old  question  of  religious 
faith.  Without  a  belief  in  what  cannot  be  strictly 
proved,  we  can  have  no  religion.  Keligious  faith, 
like  all  other  faith,  is  a  belief,  more  or  less  strong, 
not  only  in  the  unproved,  but  in  what  may  not  be 
susceptible  of  logical  proof  The  practical  point,  in 
this  relation,  which  alone  can  lead  to  any  profitable 
result,  is  the  question,  where  rigorous  proof  shall 
end  and  religious  faith  begin  ;  and  this  question  ad- 
mits of  profitable  difference  of  opinion.  Beginning 
with  mechanical  force,  and  ascending  to  muscular 
agency  and  to  the  other  signs  of  physical  vitality, 
to  sense,  and  through  the  intellectual  machinery 
controlled  by  the  will  to  the  will  itself,  the  indi- 
vidual, the  Ego,  and  so  upward  to  higher  Power,  it 
may  well  be  a  question  of  speculation  and  differ- 
ence of  opinion,  at  what  point  of  this  ascending 
scale  human  investigation  and  discovery  will  ulti- 
mately stop.  You  can  now  breed  and  hybridize 
both  plants  and  animals.  Perhaps  some  philosopher, 
with  a  better  understanding  of  the  proximate  ma- 
chinery of  life,  may  hereafter  animate  matter  by 
some  new  method.  But  the  vitality  of  the  body  is 
not  the  whole  being.  That  some  of  the  seemingly 
inscrutable  machinery  of  what  we  call  life  may  be 
within  the  limit  of  our  comprehension,  as  the  result 


67 

of  future  rigorous  observation  and  deduction,  is  not 
impossible.  But  it  is  absurd  to  suppose  that  the 
Ego,  the  individual,  can  ever  comprehend  itself.  At 
some  point  short  of  this,  investigation  must  stop  ; 
and  it  is,  then,  for  the  philosopher  to  determine 
whether  he  will  reject  a  belief  in  the  existence  of 
everything  which  lies  beyond,  or  accept  something 
on  faith,  —  which  in  this  case  is  belief,  more  or  less 
strong,  in  a  hypothesis  of  cause  working  outside  the 
material  system,  based  on  and  derived  from  all  we 
have  seen,  experienced,  and  inferred  of  constant  and 
seemingly  necessary  precedence  of  force,  or  what- 
ever one  may  choose  to  call  it,  within  that  system. 
It  seems  to  me  better  and  more  consistent  logic 
to  accept  and  to  act  on  this  uncertain  knowledge 
than  to  reject  it,  especially  in  view  of  the  fact  that 
most  of  our  unhesitating  and  daily  action  is  based 
on  equally  uncertain  knowledge. 

Such  are  the  aspects  and  tendencies  of  Material- 
ism at  the  present  day,  about  which  medical  men 
are  popularly  supposed  to  have  an  opinion.  But,  in 
the  mean  time,  the  student  of  medical  science  has 
his  hands  full  of  work  with  Pathology  and  kindred 
studies,  and,  as  a  rule,  knows  little  and  thinks  less 
of  these  speculations. 

Let  us  now  briefly  review  the  medical  departs 
ment  of  the  German  University, —  the  undisputed 
head  of  medical  teaching  at  the  present  day,  wheth- 
er we  regard  its  quality  or  quantity ;  for  although 
much  of  this  may  be  impossible  to  us,  there  may 


68 


be  also  something  that  will  point  us  in  the  direction 
of  an  improved  system  of  teaching  in  this  country. 

The  parental  care  of  the  German  Government  for 
institutions  of  learning  is  such,  that  the  number 
of  medical  schools  is  limited  only  by  their  clinical 
and  anatomical  possibilities,  being  before  the  pres- 
ent war  not  far  from  twenty,  while  the  number  of 
teachers  is  enormous. 

Nominating  their  own  officers,  enjoying  a  certain 
power  of  action  independent  of  Government,  and 
not  unfrequently  without  Government  subsidy,  these 
schools  contain  three  classes  of  teachers,  —  the  regu- 
lar or  so-called  ordinary  j^^^ofessors,  who  alone  are 
members  of  the  faculty,  the  extraordinary  profes- 
sors, and  i\ie^  private  teachers,  —  the  last  two  classes 
comprising  the  teachers  of  specialties. 

Any  vacancy  in  the  corps  of  ordinary  professors 
is  publicly  advertised  ;  applications  are  wholly  un- 
restricted ;  and  from  the  applicants  one,  two,  or 
three  are  selected  by  the  faculty  for  nomination,  — 
practically  an  appointment,  inasmuch  as  the  first 
on  the  list  receives  the  formal  appointment  then 
made  by  the  King :  an  impartial  system,  which, 
by  insuring  the  place  to  the  best  man,  excites 
an  active  emulation  among  the  professors  of  the 
lesser  universities  for  promotion  to  the  larger  and 
more  important  centres  of  instruction.  With  abil- 
ity thus  guarantied,  the  professor  holds  his  place 
for  life,  but  may  retire  on  full  pay  at  the  end  of 
thirty  years  of  service,  —  this  pay  being  about  a 
thousand  dollars  from  the  Government,  an  amount 


69 


sometimes  increased  to  three  or  four  thousand  dol- 
lars by  students'  fees,  both  to  professors  for  private 
courses  and  to  the  faculty.  While  the  professor 
is  thus  secure  of  a  minimum,  he  is  at  once  stimu- 
lated to  excellence  in  his  own  teaching  and  inter- 
ested in  the  success  of  the  whole  faculty,  —  con- 
siderations neither  of  which  should  be  lost  sight  of 
in  the  organization  of  a  school. 

Of  the  ordinary  professors,  the  more  important, 
perhaps,  are  the  clinical  professors,  w  ho  range  over 
all  medical  subjects  in  tw^o  separate  and  parallel 
courses  of  lectures,  devoting  one  to  what  we  call 
didactic,  and  the  other  to  clinical  teaching,  never 
confounding  the  two.  Chemistry  and  Physics  being 
part  of  the  preliminarj^  course,  there  are  no  profes- 
sors of  these  branches  within  the  ficulty. 

The  place  of  the  ordinary  professor  is  no  sinecure. 
He  sometimes  devotes  from  ten  to  fifteen  hours  a 
week  to  teaching.  Virchow  announces  about  eigh- 
teen hours  a  week  with  the  students,  some  of  these, 
however,  being  delegated  to  an  assistant,  —  and  the 
Professor  of  Anatomy  more.  Moreover,  in  order 
that  the  student  may  be  sure  of  a  complete  course 
of  instruction,  the  faculty  have  the  right  to  call  on 
any  professor  for  lectures  outside  of  his  immediate 
branch,  it  being  understood,  that,  the  more  lectures 
he  gives,  the  larger  wdll  be  his  receipts  :  a  rule 
steadily  enforced,  and  the  more  easily  because  it  is 
understood  that  the  two  clinical  professors  alone,  out 
of  the  whole  faculty,  are  engaged  in  the  practice  of 
medicine  or  surgery. 


70 


In  order  to  prevent  an  otherwise  necessary  increase 
of  the  faculty  proper,  there  is  an  indefinite  number 
of  additional  and  so-called  extraordinary  jjrofessors, 
not  members  of  the  fliculty,  nominated  by  this  body 
from  among  the  private  teachers,  appointed  by  the 
Minister  of  Instruction,  holding  their  places  fur  life, 
and,  unless  theh'  subject  is  very  unattractive,  de- 
pendent for  fees  wholly  on  their  classes.  These 
extraordinary  professors  often  give  parallel  courses 
upon  the  same  specialty  :  a  competitive  method,  ob- 
viouslv  contributino'  to  oood  instruction. 

^  CO 

In  the  larger  Universities  the  number  of  profes- 
sors constituting  the  faculty  proper,  and  of  the  ex- 
traordinary professors  teaching  specialties,  is  about 
a  dozen  each :  the  former  comprehending  professors 
(in  some  cases  two)  of  Anatomy,  Physiology,  Pathol- 
ogy, Morbid  Anatomy.  Materia  Medica,  Obstetrics 
and  Diseases  of  Women,  Clinical  Surgery,  Clmical 
Medicine,  and  Medical  Jurisprudence  ;  while  the 
extraordinary  professors,  teachers  of  j^ermanent  spe- 
cialties, mav  be  desio-nated  in  g-eneral  terms  as 
those  of  Histology,  the  Skin,  the  Eye,  Dentistry, 
Syphilis,  Diseases  of  Children,  Surgical  Apparatus 
and  Bandages,  Comparative  Anatomy,  Special  Medi- 
cine and  Surgery,  Mental  Diseases,  and  Veterinary 
Diseases. 

Private  teacher^  are  appointed  by  the  faculty  to 
give  instruction  upon  any  subject  within  the  range 
of  medical  science,  with  the  sole  restriction  that 
they  may  not  give  gratuitous  courses  upon  any  sub- 
ject on  which  a  professor  gives  lectures  not  gratu- 


71 


itous :  a  provision  which  seems  to  imply  that  it  is 
well  to  nourish  professorial  teaching  with  money. 
They  lecture  in  the  halls  of  the  University,  their 
instruction  being  official,  and  published  as  such  in 
the  official  catalogue.  Their  number  is  unlimited, 
being  at  Vienna  about  thirty,  at  Berlin  twenty,  and 
a  dozen  at  Breslau,  where  the  students  number  re- 
spectively about  a  thousand,  four  hundred,  and  one 
hundred  and  fifty. 

With  this  machinery  the  medical  faculty  receives 
from  the  Government  a  guarantied  monopoly  of 
medical  teaching,  while,  on  the  other  hand,  the 
public  and  the  medical  student  have  an  equal  guar- 
anty of  the  completeness  of  instruction  practically 
unlimited  in  extent,  and  whose  excellence  is  insured 
by  the  competitive  emulation  of  its  teachers. 

At  the  outset  of  the  German  student's  career  we 
are  impressed  by  the  character  of  the  qualifications 
necessary  for  admission  to  medical  study,  which,  in- 
deed, do  not  differ  materially  in  degree,  though  per- 
haps in  kind,  from  those  required  for  admission  to 
the  undergraduate  department  in  our  Universities, 
yet  are  higher,  I  regret  to  say,  than  those  which  a 
large  majority  of  our  medical  students  could  meet. 
But  it  is  not  the  preliminary  knowledge  required 
by  the  German  University  that  we  in  this  country 
miss,  so  much  as  the  resultant  culture  and  mental 
training,  the  capacity  for  study :  in  this  we  are  com- 
pelled to  acknowledge  that  the  American  medical 
student  has  large  room  for  improvement. 

The  year  is  divided  into  two  terms,  together  oc- 


72 


cupying  about  ten  months,  and  the  time  devoted  to 
medical  study  is  nowhere  less  than  four  years,  and 
in  the  larger  faculties  five  years,  —  the  result  of 
which,  with  the  previous  mental  training,  added  to 
extended  opportunities  for  the  acquisition  of  modern 
medical  science  under  the  best  instructors,  we  can- 
not afford  to  overlook.  It  will  hardly  be  credited 
that  there  are  at  Berlin,  in  each  week,  three  hun- 
dred and  forty-one  hours  of  medical  instruction, 
and  at  Vienna  three  hundred  and  seventeen,  —  al- 
though the  student  may  be  required  to  attend 
lectures  amounting  in  the  average  to  twenty  or 
thirty  hours  only,  a  week. 

With  the  single  restriction  that  the  study  of 
Clinical  Medicine  and  Surgery,  and  Midwifery, 
cannot  be  entered  upon  until  the  completion  of 
the  more  elementary  branches,  and  receiving  mere- 
ly general  advice  from  the  faculty,  the  student 
is  left  to  himself  to  choose  among  the  various  op- 
portunities for  instruction,  being,  as  a  rule,  required 
to  devote  the  first  half  of  his  four  or  five  years  to 
the  elementary  and  theoretical  studies,  notwithstand- 
ing a  common  desire  to  attend  the  hospitals ;  and 
certificates  of  actual  attendance  upon  these  branches 
are  rigorously  exacted.  The  teacher  is  supposed  to 
acquire,  to  some  extent,  a  personal  knowledge  of 
each  student ;  and  the  student,  in  turn,  is  at  liberty 
to  select  his  teachers  in  the  parallel  courses,  w^iich 
for  the  first  ten  days  are  gratuitous,  to  fiicilitate  his 
choice.  This  liberty  of  choice  is  also  extended  to 
the   different  Universities,  so   that  a   student   may 


73 


pass  from  one  distinguished  professor  to  another, 
ultimately  complying  with  the  formalities  of  exam- 
ination in  that  University  only  at  which  he  grad- 
uates. But  it  should  be  remembered  that  these 
examinations  are  an  actual  and  rigorous  test  of  the 
student's  knowledge. 

Medical  teaching  rests  largely  on  clinical  oppor- 
tunity. The  collective  hospital  at  Vienna  is  im- 
mense, and  it  might  be  anticipated  that  a  part  only 
of  this,  and  even  of  hospitals  in  smaller  cities,  would 
be  profitably  available  for  medical  instruction.  The 
Government  wisely  interferes  and  provides  for  this 
emergency,  by  alloAving  a  clinical  professor  to  select 
from  the  whole  hospital  establishment  cases  suited 
to  the  purposes  of  instruction,  and  also  to  remove 
from  his  wards  such  as  are  no  longer  profitable  or 
interesting  to  the  students,  who  have  thus  the  very 
great  advantage  afforded  by  an  unlimited  number 
of  selected  cases. 

All  hospital  autopsies  are  made  by  the  school 
professor  of  Pathological  Anatomy,  who  selects  cases 
as  in  the  wards.  These  autopsies  are  made  inde- 
pendently of  the  clinical  professor  who  has  had 
charge  of  the  cases  ;  and  while  the  latter,  in  treat- 
ing the  disease,  has  been  expected  to  lecture  upon  it 
in  detail,  and  to  furnish  to  the  students  a  carefully 
recorded  diagnosis,  the  j^athological  professor  makes 
before  the  class  an  equally  detailed  demonstration 
of  the  autopsy,  also  accurately  recorded,  impartially 
verifying   or  disproving    the   views   of  the   clinical 

10 


74 


professor.  The  student  further  follows  the  case, 
if  he  desires,  from  the  autopsy  to  the  microscope 
room. 

In  short,  the  hospital  patient,  from  first  to  last, 
subserves  the  requirements  of  the  student  to  an 
extent  impossible  in  this  country. 

Physiology,  Physiological  Chemistry,  and  Vivi- 
section are  taught  in  appropriate  apartments  and 
laboratories. 

No  one  can  fail  to  be  struck  with  the  eminently 
practical  character  of  the  medical  examinations,  and 
with  the  fact  that  they  are  calculated  to  determine 
indisputably  the  degree  of  proficiency  in  the  various 
branches  of  medical  studv.  The  student  is  tested 
by  the  professors,  in  presence  of  the  patient,  in  the 
autopsy  room,  in  the  laboratories,  in  short,  in  every 
useful  way,  by  examinations.  These  examinations 
take  place  at  irregular  periods  of  the  course,  and  we 
are  not  surprised  to  find  that  a  large  number  of  stu- 
dents are  turned  back  at  different  stages  of  their 
progress.  And  if  the  protracted  term  of  study  — 
four  or  five  years,  at  the  least,  as  already  stated  — 
detains  the  student  long  under  the  eye  of  the  pro- 
fessor, and  so  tends  to  educate  him  rather  as  a  fol- 
lower than  an  independent  leader,  it  should  be  re- 
membered that  its  machinery  is  arranged  to  encour- 
age him  at  every  step  to  try  his  own  powers  of 
flight,  and  practise  him  in  the  exercise  of  his  own 
judgment. 


75 


In  a  word,  —  a  medical  school  virtually  appoint- 
ed and  carried  on  by  medical  men,  —  a  teaching 
based  mainly  upon  large  clinical  opportunity  and 
an  abundant  and  accurate  demonstration  of  medi- 
cal facts,  —  life  and  activity  grounded  upon  emula- 
tion, —  a  system  guarantying  to  the  soundest  teach- 
er the  widest  reputation  and  the  largest  classes,  with 
an  unrestricted  freedom  of  competition,  especially 
in  the  outset,  and  holding  out  as  its  final  prize  a 
permanent  tenure  of  its  highest  offices  with  an  ade- 
quate remuneration,  —  such  are  the  elements  of  the 
great  success  of  modern  German  medical  education, 
with  its  underlying  principle  of  practical  instruction 
in  all  branches  that  admit  of  practical  demonstra- 
tion. 

He  who  comes  home,  fresh  from  German  opportu- 
nities, and,  impressed  with  their  obvious  advantages, 
attempts  to  incorporate  the  German  into  the  ac- 
cepted American  system,  will  find  that  this  luxuriant 
growth  of  another  hemisphere  is  not  wholly  adapted 
to  our  soil  or  to  our  requirements.  He  must  sup- 
plant public  opinion  by  a  central  government  su- 
preme in  all  matters  pertaining  to  education  and 
hospital  administration,  replace  the  American  with 
the  German  professor,  and  the  American  student 
with  the  German  student. 

In  Germany,  the  Government  enforces  a  sj^stem 
which  distributes  a  number  of  salaried  places,  con- 
ferring high  distinction,  impartially  to  the  best  men  ; 
and  in  thus  offering  large  pecuniary  prizes  to  scien- 


76 


tific  merit,  in  a  country  where  the  mass  of  the  people 
are  j^oor,  makes  Science  itself  a  field  of  active  emu- 
lation ^vhich  has  no  ulterior  professional  aim.  This 
cannot  be  expected  here. 

To  the  foreigner,  the  especial  attraction  of  Vi- 
enna—  as  of  Paris  formerly — is,  that  the  student 
who  desires  instruction  upon  any  one  of  twenty  or 
twice  twenty  different,  yet  distinctly  medical  or  sur- 
gical subjects,  of  every-day  use  to  the  practitioner, 
can,  with  half  a  dozen  of  his  friends,  induce  an  able 
teacher,  for  a  moderate  compensation,  and  with 
every  facility  for  clinical  or  anatomical  illustration 
at  command,  to  exhaust  the  subject  for  their  par- 
ticular benefit.  The  knowledge  is  exactly  wdjat 
you  want,  imparted  when  you  want  it,  and  by  a 
teacher  with  whom  you  are  brought  into  close 
personal  relations.  But  it  is  an  error  to  confound 
the  idea  of  this  medical  knowledge  proper  wnth  any 
vague  notion  of  a  higher  education  and  a  higher  sci- 
ence to  result  from  extended  collateral  study.  Let 
us  distinctly  bear  in  mind  that  the  American  medical 
student  abroad  commonly  has  little  to  do  w^ith  either 
Phj'siology  or  even  Chemistry,  unless  he  pursues  it 
as  a  special  branch  of  study,  and  for  some  purpose 
other  than  the  practice  of  medicine. 

Paris,  once  the  Mecca  of  the  medical  student,  has 
^delded  to  the  predominance  of  the  German,  in  sci- 
ence, as  in  arms,  partly  through  the  original  indirect 
influence  of  the  common  school,  —  because,  while 
France    means   Paris    only.  Northern   Germany,   in 


77 


the  words  of  Colonel  StofFel,  is  "  covered  with  cen- 
tres of  intellectual  activity  and  production,  so  that, 
to  enumerate  them  all,  one  has  to  go  down  to 
towns  of  the  third  and  fourth  rank,"  the  average 
intellectual  level  being  everywhere  higher.  But 
I  think  we  must  avow,  that,  apart  from  mere  edu- 
cation, there  is  something  in  the  original  character 
of  the  German  people,  a  solid  and  unattractively 
plain  folk,  which  stamps  it  as  different  from  the 
genius  of  the  French  or  the  American  people.  It 
has  been  called  a  sense  of  duty ;  but  it  seems  to 
me  to  be  rather  an  instinct  of  labor  without  per- 
sonal ambition.  To  quote  Colonel  Stoifel  again  : 
"  One  never  ceases  to  be  astonished  by  it,  no  matter 
how  much  one  studies  the  Prussian  people.  The 
most  remarkable  ilhistration  of  this  is  furnished  by 
the  employes  of  all  grades  in  the  different  branch- 
es of  the  administration  of  the  monarchy.  They  are 
paid  with  surprising  parsimony,  they  are  generally 
burdened  with  families,  and  yet  they  toil  all  day 
long  with  indefatigable  zeal,  without  complaining, 
and  without  appearing  to  desire  an  easier  position. 
'  We  take  good  care  not  to  meddle  with  it,'  said 
M.  Bismarck  to  me  one  day;  'this  laborious  and 
badly  paid  bureaucracy  does  the  best  part  of  our 
work,  and  constitutes  one  of  our  principal  forces.' " 
What  is  this  but  instinctive  labor,  the  patient  rou- 
tine of  the  bee,  rather  than  the  expanding  aspira- 
tion generated  by  American  soil  ?  —  and  I  intend 
no  "  spread-eagleism  "  in  this  remark. 

Until  that  distant  period  when  the  whole  flice  of 


78 


our  country  shall  be  changed,  until  this  great  con- 
tinent is  so  crowded  with  struggling  life,  and  so 
hopelessly  oppressed  with  the  superposed  strata  of 
political  and  conventional  form,  that  no  individual 
can  upheave  the  social  sediment  and  lift  himself 
into  the  active  world,  but  by  sheer  habit  and  the 
force  of  circumstances  shall  continue  in  the  last  half 
of  his  life  to  investigate  the  simple  cell  that  occu- 
pied his  younger  years,  there  will  be  few  world- 
distinguished  scientists,  in  limited,  special  spheres, 
here,  as  in  Europe.  The  mass  of  human  knowledge 
grows,  indeed  ;  but  many  years  must  elapse  before 
we  can  expect  such  growth  in  this  country,  before 
scientists  will  look  to  an  American  city,  as  to  the 
Vienna,  the  Berlin,  or  even  the  Paris  of  Medical 
Science.  And  in  the  mean  time  our  country  needs 
well-qualified  medical  practitioners. 

The  considerations  which  have  been  offered  with 
regard  to  the  capacity,  the  wants,  and  the  time  of 
the  medical  student,  and  also  with  regard  to  the 
tendencies  of  modern  medical  science  and  instruc- 
tion, present  a  wide  field  for  serious  reflection. 
American  medical  education  should  guaranty  to 
the  student  of  average  preliminary  training  and 
acquirement,  who  has  honestly  devoted  three  years 
to  medical  study,  a  knowledge  at  once  adequate  to 
the  immediate  practice  of  his  profession,  and  a  germ 
of  future  growth  in  the  right  direction,  —  knowl- 
edge unmistakably  medical,  practical,  comprehensive, 
and  rooted  in  the  soil  of  modern  science. 


79 


In  this  vigorous  country,  where  the  pursuits  of 
business  exhibit  so  many  striking  examples  of  early 
capacity,  and  where  the  aim  of  every  young  man  is 
to  find  himself  in  active  life,  it  is  plainly  difficult  to 
fetter  the  ambition  of  the  student  with  a  view  to 
insuring  greater  conventional  and  average  compe- 
tency. American  medical  colleges,  too,  are  engaged 
in  active  competition  to  secure  the  largest  classes. 
If  public  opinion  has  prevented  the  better  institu- 
tions from  reducing  their  standard  of  attainment 
much  below  a  point  concerning  which  there  has 
been  a  tacit  understanding,  it  is  safe  to  say  that  no 
successful  school  has  thought  proper  to  risk  large 
existing  classes  and  large  receipts  in  attempting  a 
more  thorough  education.  Steps  in  this  direction 
have  been  guided  rather  by  a  desire  to  attract  larger 
classes,  —  and  perhaps  by  a  conviction,  that,  while 
we  must  accept  a  certain  amount  of  inferiority,  the 
standard  of  medical  education  in  this  country  may 
be  raised,  in  the  future  as  in  the  past,  gradually  and 
with  certainty,  by  making  the  best  opportunities 
available  to  the  largest  number. 

Whatever  opinion  be  entertained  of  this  policy,  it 
will  be  conceded  that  it  differs  from  one  which  abso- 
lutely exacts  from  the  medical  student  more  knowl- 
edge, and  resolutely  refuses  a  degree  (too  often  per- 
haps regarded  as  mere  authority  to  open  day-book 
and  ledger)  until  he  shall  comply  with  the  increased 
requisitions,  —  requisitions  not  of  a  mere  formal 
and  technical  character,  but  a  guaranty  of  increased 
practical  skill  in  every  branch  of  the  medical  art. 


80 


Such  is  the  object  of  measures  recently  maugu- 
rated  in  the  Medical  School  of  Harvard  University, 
upon  which  the  Massachusetts  Medical  Society  now 
mainly  relies  for  the  education  of  Massachusetts  stu- 
dents, —  measures  adopted  by  its  professors  in  a 
spirit  of  personal  sacrifice,  with  a  full  sense  of  the 
possibilities  they  may  entail  of  increased  labor  and 
diminished  pecuniary  receipts,  and  of  which  I  feel  it 
incumbent  on  me  here  to  say  that  whatever  credit 
attaches  to  them  is  due  to  my  colleagues,  and  to  the 
President  of  the  University. 

By  the  newly  adopted  plan,'^  the  term  of  study 
still  being   three   years,   no   student  can  receive   a 

*  It  may  be  stated,  for  the  information  of  those  not  familiar  with 
medical  education  in  this  country,  that  the  student,  before  he  can  be 
examined  for  the  degree,  must  have  studied  medicine  three  years,  and 
also  have  attended  two  courses  of  lectures  in  a  medical  college  author- 
ized by  law  to  confer  degrees. 

The  present  u«ual  or  winter  course  of  lectures  lasts  four  or  five  months. 
Its  advantages  are,  that  it  saves  money  to  the  student,  to  whom  city  board 
during  a  long  consecutive  period  is  often  impossible,  and  who  on  that 
account  is  frequently  obliged  to  content  himself  with  one  course  of  lec- 
tures in  a  city  school.  —  and  that  it  also  economizes  the  time  of  the  in- 
structor, usually  a  practising  physician,  to  whom  it  may  be  desirable 
to  concentrate  his  teaching  into  a  part  of  the  year. 

The  disadvantages  of  this  system  relate  chiefly  to  its  necessary  conden- 
sation, which  begets  a  want  of  completeness  in  its  teaching,  —  defects, 
however,  which  in  our  own  University  have  been  largely  compensated 
by  its  summer  term  or  school,  which  has  furnished  to  the  student  who 
could  afford  it  a  supplementary  and  comparativt-ly  thorough  instruction. 
This  school,  the  first  I  believe  in  this  country  officially  identified  with  a 
medic il  college,  was  also  one  of  the  most  complete  in  its  organization. 

Harvard  University  has,  indeed,  long  offered  to  the  medical  student 
great  advantages  ;  and  it  was  no  deficiency  in  its  teaching,  compared  with 
that  of  any  other  college  in  this  country,  that  suggested  a  change  in  its 
pl;in  of  mediciil  Instru'-tion. 


81 

degree  from  this  school  who  has  not  been  connected 
with  it  at  least  one  year.  A  progressive  system 
of  study  of  three  years'  duration,  beginning  with 
the  elementary,  and  ending  with  the  higher  and 
more  exclusively  medical  branches,  including,  as  a 
matter  not  of  form,  but  of  reality,  all  the  inter- 
mediate subjects  of  medical  study,  offers  to  the  stu- 
dent, who  can  devote  three  years  to  it,  what  must 
be  considered,  in  this  country  at  least,  a  very  com- 
plete medical  education.  It  involves,  as  will  be  seen, 
the  necessity,  in  part,  of  three  concurrent  courses 
of  instruction  during  each  year.  The  student  who 
joins  this  school  for  two  years,  or  even  for  one  year, 
may,  if  he  pleases,  by  closer  application  to  study, 
avail  himself  of  these  three  courses  simultaneously, 
with  the  obvious  advantage  of  expanding  the  for- 
mer winter  course  into  a  year  or  two  years  of  pro- 
gressive study  during  his  one  or  two  years  in  the 
school. 

A  part  of  a  year  in  the  Harvard  Medical  School, 
or  a  part  of  a  year  in  any  other  school,  will  count 
in  either  case  only  as  time,  and  not  as  a  "course 
of  lectures,"  —  a  measure  inuring  to  the  benefit  of 
other  colleges,  in  sending  to  them  any  student  w^ho 
desires  that  two  "winter  courses"  of  four  months 
each  should  entitle  him,  as  now,  to  examination  for 
a  deo-ree  in  the  colleore  at  which  he  takes  one  of 
those  courses.  On  the  other  hand,  Harvard  College 
will  so  examine  any  student,  who,  having  complied 
with  all  other  usual  requirements,  shall  have  taken 
at  least  one  full  year's  course  of  study  in  its  own 
11 


82 


school,  —  a  measure  which,  whatever  else  may  be 
said  of  it,  insures  to  the  student  a  higher  standard 
of  acquirement  than  has  been  yet  exacted  in  this 
country,  in  view  of  two  facts :  first,  the  progres- 
sive teaching  attained  by  abandoning  the  winter 
course  ;  second,  its  requirement  of  competency  in 
all  the  nine  departments  of  study,  —  a  competency, 
however,  which  is  more  easily  attainable,  because  it 
may  be  practically  and  finally  tested  in  any  one  or 
more  branches,  at  the  option  of  the  student,  at  any 
one  of  three  annual  examinations,  failing  in  which, 
he  may  try  again,  when  he  likes,  in  those  branches 
alone. 

I  heartily  join  with  my  associates  in  hoping  that 
these  carefully  considered  measures  will  accomplish 
the  special  purpose  for  which  they  have  been  adopt- 
ed, that  of  raising  the  standard  of  medical  education 
in  this  country. 

I  betray  no  confidence  in  saying  that  some  of  my 
able  colleagues  would  have  been  glad  to  insist  upon 
at  least  a  two  years'  residence  here.  My  own  con- 
viction has  been  that  we  are  clearly  not  justified  in 
doing  anything  seriously  to  endanger  the  present 
large  success  of  the  institution  we  have  hitherto 
administered.  In  the  recent  words  of  one  of  the 
great  reformers  of  the  day:  "If  we  attempt  to  go 
too  far  ahead  of  the  community,  we  may  be  left  too 
far  behind.  He  ventured  to  think  that  a  system 
which  would  gain  the  attention  and  respect  of  the 
people  must  be  one  not  too  rudely  divorced  from 
their  old  system.     He  wanted  to  see  the  adoption, 


83 


by  the  Board,  of  regulations,  not  in  accordance  with 
what  he  might  think  right  or  otherwise,  but  capable 
of  niovino;  in  the  direction  in  which  thouo;ht  was 
moving "  :  *  I  would  add,  in  the  direction  of  that 
enlightened  public  opinion  which  in  this  country  is 
the  legitimate  directing  power  in  education,  and 
which,  as  I  interpret  it,  would  open  to  the  medical 
student  a  most  liberal  scientific  opportunity,  and  in- 
sist upon  a  competency  strictly  medical. 

*  From  remarks  of  Pror.*s**nr  Huxley  on  the  Bible  in  London  Schools: 
Boston  Daily  Arhrrtiser,  March  29,  1871. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

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This  book  is  DUE  on  the  last  date  stamped  below. 


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